Urinary Incontinence and Neuro-urology


What is Urinary Incontinence?

Urinary Incontinence is the unintentional passing of urine and urinary leakage. It occurs when the normal process of passing urine out of the body is disrupted.

There are general factors that may increase the chance of urinary incontinence developing. These include:

  • Pregnancy and vaginal birth
  • Obesity
  • Family history of urinal incontinence
  • Increasing age
  • Taking certain antidepressants
  • Hormone replacement therapy
  • Taking other medications including diuretics, angiotensin- converting enzyme (ACE) inhibitors and sedatives
  • Neurological conditions, such as Parkinsons disease, multiple sclerosis, a brain tumour, a stroke or spinal injury can interfere with nerve signals to the bladder and cause incontinence. In these cases, treatments developed from neuro-urology can benefit (see neuro-orology and treatment for urge incontinence).

Otherwise, the causes and symptoms depend on the type of urinary incontinence.

The two most common types of urinary incontinence are stress incontinence and urge incontinence.

Types of Incontinence

Stress incontinence occurs when pressure is placed on the bladder (where urine is stored). Sometimes the pressure on the bladder becomes greater than the strength of the urethra (the tube through which urine passes out of the body) to stay closed, causing the unintentional passing of urine. Coughing, laughing or sneezing can cause sudden pressure and urinary leakage. Other activities that may cause urinary leakage include exercise and heavy lifting. The level of urine leakage this causes is usually low but can be higher if your bladder is full.

Stress incontinence is usually caused by the weakening of the pelvic floor muscles or the urethral sphincter (the ring of muscle that prevents urine flowing from the bladder into the urethra). Common causes for this include damage during childbirth, increased pressure due to through pregnancy or obesity, damage to the bladder during surgery or a connective tissue disorder such as Ehrlers- Danlos syndrome.

Urge incontinence occurs when there is a sudden intense urge to pass urine. There is usually only a few seconds between the urge to urinate and the passing of urine, resulting in urine leakage.

Urge incontinence is usually caused by overactive detrusor muscles (the muscles that control the bladder). These muscles relax to allow the bladder to fill with urine then contract to release urine when going to the toilet. When the detrusor muscles contract to often the bladder can be described as being ‘overactive.’ Common causes of urge incontinence include drinking too much alcohol or caffeine, not drinking enough fluids, constipation, urinary tract infections or in some cases tumours in the bladder.

Mixed incontinence is a combination of both stress incontinence and urge incontinence. Usually one type of incontinence will be more prevalent than the other.

Overflow incontinence occurs when the bladder does not fully empty when passing urine, causing it to swell above its usual size. Urinary leakage occurs very often in small trickles and you may experience the sensation of your bladder never being completely empty. This is often due to a blockage or obstruction to the bladder that prevents it from being emptied as normal. The bladder will still fill up as normal and this creates a build up behind the obstruction, causing frequent urine leakage. This can be caused by damage to the nerves, constipation, or an enlarged prostate gland in men.

Total incontinence occurs when the unintentional passing of urine becomes heavy and continuous. You may pass large amounts of urine all the time or occasionally and experience small amounts of urinary leakage in between. This form of urinary incontinence happens when the bladder cannot store any urine at all. This can be caused by a problem with the bladder from birth, injury to the spinal cord or a bladder fistula (a small tunnel that can form between the bladder and a nearby area).

Treating Urinary Incontinence

When considering whether to have surgery and what type of surgery to have it is important to consult with a specialist. Our Bristol based urology surgeons will be able to offer expert advice and recommendations based on your condition and your needs.

Lifestyle changes are usually necessary to completely treat urinary incontinence, for example reducing caffeine or fluid intake, losing weight, pelvic floor muscle training or bladder training.

Medications may be recommended to treat incontinence.  Those with stress incontinence may be offered medication that helps keep the urethra closed by strengthening the muscle tone. Those with urge incontinence may be offered medication used reduce bladder muscle activity.

Surgical treatment may be considered if other treatments for urinary incontinence are unsuccessful. Outlined below are the different types of surgical procedures for stress incontinence and urge incontinence.

Surgeries for Stress Incontinence

Tape procedures are surgical procedures used to treat stress incontinence in women.

  • An incision (a cut) is made inside the vagina
  • A piece of plastic tape is inserted through the incision and threaded behind the urethra
  • Two more incisions are made in either the top of the inner thigh or the abdomen (tummy)
  • The middle part of the tape is used to support the urethra, while the two ends of the tape are threaded through the incisions made in the thigh or the abdomen
  • The tape holds the urethra up in the correct position and reduces urinary leakage

Two in every three women with stress incontinence will not experience any leaking following a tape procedure. When leaking is still experienced, it will be less severe than before the surgery.

A common side effect of this surgery is the need to go to the toilet more often and some women may find they are unable to empty their bladder fully when they do. The tape can wear away over time and further surgery may be needed later on to adjust or remove it.

Colposuspension is used to treat women and occasionally men for stress incontinence.

  • An incision is made in the lower abdomen
  • The neck of the bladder is lifted upwards and stitched in place
  • In what is called an open colposuspension the surgery is carried out through a large incision
  • In what is called a laparoscopic colposuspension surgery is carried out through smaller incisions using special surgical instruments

Side effects of this procedure include not being able to empty the bladder fully when going to the toilet, urinary tract infections and discomfort during sex.

Sling procedures are used to treat women with stress incontinence.

  • Tissue is taken from another part of the body
  • This tissue is used to construct a sling that will be used to support the bladder
  • An incision is made in the lower abdomen and the vagina
  • The sling is placed under the urethra then passed through the muscles in the abdomen and tightened around the urethra

The sling acts as a support for the bladder and reduces urinary leakage. The process outlined above is for what is called an autologous sling which is the most common form of sling procedure. However there are other procedures where the sling will be made from synthetic material, animal tissue or tissue donated from another person.

There is also a type of sling procedure used to treat stress incontinence in men.

  • Three small incisions are made, one in each groin and one in the perenium (just below the back passage)
  • A synthetic mesh sling is inserted around the urethra

The recovery process after a sling procedure will usually consist of one- two nights in hospital depending on whether you are male or female (you should consult your urologist about this).

The most common side effects of the sling procedure include needing to go to the toilet more frequently and an inability to empty the bladder fully when doing so. Sometimes urge incontinence can develop in women following the surgery although this is less common.

Urethral Bulking Agents are substances used to treat women with stress incontinence.

  • A thin viewing tube called a cystoscope is inserted directly into the urethra
  • The bulking agent is injected through the cytoscope

Side effects can include a burning sensation or bleeding when passing urine for a short time following the injection.

Although this procedure is a lot simpler than other procedures and no incisions need to be made it is generally less effective and can require repeated injections as the agent wears off over time.

Artificial Urinary Sphincter aims to treat stress incontinence mainly in men and rarely in women. It involves fitting an artificial urinary sphincter to prevent urine leakage.

  • A small incision is made between the scrotum and the anus
  • A circular cuff is placed around the urethra
  • Another incision is made in the groin
  • A pump is placed in the scrotum an a balloon reservoir is placed behind it

The cuff fills with fluid to compress the urethra when necessary, stopping unintentional passing of urine. The pump controls the flow of fluid to and from the cuff. The fluid passes between the pump and the reservoir as the device is activated and deactivated.

Common side effects of this procedure include a burning sensation and bleeding when passing urine for a short period following the surgery. The device may stop working in the long term and further surgery will be required to remove it.

Surgeries for Urge Incontinence

Sacral nerve simulation is a type of neuro-urology used to treat urge incontinence. It is recommended in cases where urinary incontinence is caused by overactive detrusor muscles.

  • An electrode is inserted into the lower back next to one of the sacral nerves
  • The electrode is connected to a device that generates electrical impulses for 21 days
  • You will be at home during this process and you will need to complete an ‘input/output’ chart
  • If this test is successful, the electrode will be kept permanently and a second operation will be necessary to implant a neurotransmitter

This treatment can cause discomfort but it is a very effective way at relieving or even ending urinary incontinence altogether.

Augmentation Cystoplasty can be used to treat urge incontinence by enlarging the bladder.

  • An incision is made in the lower abdomen
  • The bladder is opened and split almost in two
  • A separated part of the bowel will be stitched to re-build the bladder wall
  • The ends of the bowel will be re-joined where the part has been removed

Side effects of this treatment include not being able to urinate properly and regularly urinary tract infections.