By Dr. Dineshani Hettiarachchi Sirisena Are you a mom and have you ever peed without your knowledge? If so, you might be having pelvic floor dysfunction. The National Women’s Health and Fitness Day is celebrated on 25 September in the US. The goal of this event is to encourage women to take control of their health – to learn the facts they need to make smart health choices and to make time for regular physical activity. We want to address a less talked about topic that plagues many women through their childbearing years and beyond. Urinary incontinence, or the loss of bladder control, is a common and often embarrassing problem. Its severity ranges from occasionally leaking urine when you cough or sneeze to having an urge so sudden and strong to urinate that you can’t get to a toilet in time. Though it occurs more often as people get older, urinary incontinence isn’t an inevitable consequence of aging. To shed light on this rather embarrassing problem ladies face, we spoke to Senior Consultant Urological Surgeon and Professor of Urology at the National Hospital of Sri Lanka Prof. Neville D. Perera (MS, FRCS [Eng], FRCS [Edin], Dip Urol [Lond], FCSSL [Hon]). Urinary incontinence is defined as the passage of urine without your knowledge and control in an adult or adolescent. There can be several reasons for this. In children, it’s commonly referred to as bedwetting. Nearly 90% of children attain urinary continence by the age of five. In some others, it could be delayed up to 14 (7%) years or rarely, 21 years, without any abnormality or disease. Temporary urinary incontinence As the name suggests, this is usually transient and is due to the production of abnormally large amounts of urine in a short period of time or could be triggered by various drugs and food which irritate the bladder, thus failing to hold urine until you reach the toilet. Some such factors are:

• Alcohol
• Caffeine
• Carbonated drinks and sparkling water
• Artificial sweeteners
• Chocolate
• Chilli peppers
• Food high in spices, sugar, or acid, especially citrus fruits
• Heart and blood pressure medication (diuretics), sedatives, and muscle relaxants
• Large doses of vitamin C
• Urinary tract infection (especially in the bladder – cystitis) can irritate the bladder, causing strong urges to urinate before making to the toilet
• Constipation. The rectum is located near the bladder and shares many of the same nerves. Hard, compacted stool in your rectum causes these nerves to be overactive and increase urinary frequency

Urinary incontinence in special instances However, there are special instances in a woman that could be related to changes in bodily functions and hormonal influences that cause incontinence and some might even require medical interventions. Pregnancy – hormonal changes and the increased weight of the fetus can lead to stress incontinence

• Childbirth – vaginal delivery can weaken muscles, over-stretch the nerves needed for bladder control, and damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With a prolapse, the bladder, uterus, rectum, or small intestine can get pushed down from its usual position and protrude into the vagina. Such protrusions can be associated with incontinence
• Changes with age – aging of the bladder muscle can decrease the bladder’s capacity to store urine. Also, involuntary bladder contractions become more frequent as you get older
• Menopause – after menopause, women produce less oestrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence
• Hysterectomy (removal of the uterus) – in women, the bladder and uterus are supported by many of the same muscles and ligaments. Any surgery that involves a woman’s reproductive system, including the removal of the uterus, may damage the supporting pelvic floor muscles and nerves which can lead to incontinence

Types of urinary incontinence include:

• Stress incontinence – urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising, or lifting something heavy
• Urge incontinence – you have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate often, including throughout the night.Urge incontinence may be caused by a minor condition such as infection or a more severe condition such as a neurologic disorder or diabetes
• Overflow incontinence – you experience frequent or constant dribbling of urine due to a bladder that doesn’t empty completely
• Functional incontinence – a physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough
• Mixed incontinence – you experience more than one type of urinary incontinence

Are you at risk? There are several risk factors. The most notable among them are:

• Age – as you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release
• Obesity/overweight – extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze
• Smoking – tobacco use may increase your risk of urinary incontinence
• Family history – if a close family member has urinary incontinence, especially urge incontinence, your risk of developing the condition is higher

All are not the same. There are few types of urinary incontinence. Hence, the correct diagnosis is pivotal for appropriate treatment. Complications of chronic urinary incontinence

• Skin problems – rashes, skin infections, and sores can develop from constantly wet skin
• Urinary tract infections – incontinence increases your risk of repeated urinary tract infections
• Impacts on your personal life – urinary incontinence can affect your social, work, and personal relationships

Arriving at a diagnosis Your doctor is likely to start with a thorough history and physical exam. You may then be asked to do a simple manoeuvre that can demonstrate incontinence, such as coughing. Prof. Perera stated that if you’re diagnosed as having urinary incontinence, your doctor will decide on the appropriate treatment depending on the type of incontinence, its severity, and the underlying cause. Treatment could include a combination of the following options. If an underlying condition is causing your symptoms, your doctor will first treat that condition. Behavioural techniques Pelvic floor muscle exercises To do pelvic floor muscle exercises, or kegal exercises, imagine that you’re trying to stop your urine flow. To help you identify and contract the right muscles, your doctor may suggest you work with a physical therapist or try biofeedback techniques. Apart from these, Prof. Perera mentioned the use of electrical stimulation. However, this is not available in Sri Lanka. If these techniques fail to achieve satisfactory results, your doctor will opt for oral medication, external continuance devises such a pessaries, or even surgery to correct the problem. However, there are few lifestyle modifications one can make to avoid progression and complications. Lifestyle and home remedies Problems with urine leakage may require you to take extra care to prevent skin irritation:

• If you have urge incontinence or night-time incontinence, make the toilet more convenient. Move any rugs or furniture you might trip over or collide with on the way to the toilet and use a night light to illuminate your path and reduce your risk of falling
• If you have functional incontinence, you might keep a bedside commode in your bedroom, install an elevated toilet seat, and/or widen an existing bathroom doorway

Prof. Perera emphasised that with effective treatments available for urinary incontinence, you’ll be on your way to regaining an active and confident life.

Tests and tools for management

Urinalysis – a sample of your urine is checked for signs of infection, traces of blood, or other abnormalities. Bladder diary – record how much you drink, times you urinate, the amount of urine you passed, whether you had an urge to urinate, and the number of incontinence episodes. This has to be maintained for two days with normal activities if possible. Post-void residual measurement – an ultrasound scan to check the amount of leftover urine in your bladder, using a catheter or ultrasound test, before and after passing urine to check whether the bladder is obstructed. Urodynamic study – if bladder irritability is suspected, a urodynamic study is carried out, especially when considering surgery. Bladder training – to delay and hold on to urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between trips to the toilet until you’re urinating only every 2.5-3.5 hours. Double voiding – to help you learn to empty your bladder more completely to avoid overflow incontinence. Double voiding means urinating, waiting a few minutes, and then trying again. Scheduled toilet trips – to urinate every two to four hours rather than waiting for the need to go. Fluid and diet management – doneto regain control of your bladder. You may need to cut back on or avoid alcohol, caffeine, or acidic foods. Reducing liquid consumption, losing weight, or increasing physical activity can also ease the problem. Tighten (contract) the muscles you would use to stop urinating and hold for five seconds, and then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds.) Work up to holding the contractions for 10 seconds at a time. Aim for at least three sets of 10 repetitions each day. Use a washcloth to clean yourself. Allow your skin to air-dry – avoid frequent washing and douching because these can overwhelm your body’s natural defences against bladder infections. Consider using a barrier cream such as petroleum jelly or cocoa butter to protect your skin from urine. Ask your doctor about special cleansers made to remove urine that may be less drying than other products.   About the writer The writer, Dr. Dineshani Hettiarachchi Sirisena, is a family physician with a special interest in rare genetic diseases and regenerative medicine currently working as a lecturer at the Department of Anatomy, Faculty of Medicine, University of Colombo, Sri Lanka.