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Incontinence- The silent epidemic

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For many women urinary incontinence is a clear problem without a clear cause, or solution. The fact that one in three women who have ever had a baby wet themselves indicates the extent of this problem. Urinary incontinence is distressing and embarrassing and can impact significantly on women’s lives. The silence that surrounds urinary incontinence results in many women feeling isolated and reluctant to seek help.

The severity of urinary incontinence varies hugely between women. Some women find they loose urine occasionally when they cough or sneeze while others find it occurs frequently through the day. Women are willing to put up with different degrees of incontinence, but it is important for them to know that help is available and they don’t need to let it restrict their lifestyle.

Stress incontinence is the most common type of urinary incontinence. It occurs when the bladder neck is weakened and urine leaks out unintentionally. An overactive bladder is the other main cause of urinary incontinence. As the most common type of incontinence women experience after having a baby is stress incontinence, this will be discussed in the article.

What causes urinary incontinence?

While one in five women will experience urinary incontinence this rises to one in three women who have had a baby. While we know pregnancy and childbirth are major risk factors for incontinence the cause is likely to be due to many factors. Simply being a woman puts you at greater risk of urinary incontinence than a man. Women who have never had children are still four times more likely than men to have stress incontinence. As women get older their chance of developing stress incontinence increases. It is still quite a common belief amongst women and some health professionals that vaginal birth is the major cause of urinary incontinence. The reality is, however, that pregnancy itself is a major cause. It appears that the hormones of pregnancy such as ‘relaxin’ are largely to blame. This hormone acts to relax the connective tissues during pregnancy and they never quite return to their original state. As the pregnancy advances the weight of the baby stretches the pelvic floor muscles. During the birth the baby moves down through the birth canal (vagina), stretching the muscles and nerves that help to keep the bladder shut. This can all lead to the muscles being weak and unable to prevent the bladder from leaking, particularly when coughing, sneezing, heavy lifting or exercise. Some women it would appear are more susceptible to this occurring, but the difficulty is in correctly identifying these women. Many researchers have attempted to find the specific event that causes the incontinence but it is unlikely to be one thing. The commonly quoted risks for developing incontinence include large babies and difficult births such as those that require forceps delivery. Long periods of pushing during the last part of labour also seem to put women at increased risk.

Do caesareans prevent urinary incontinence?

Around 4% of women in Australia request elective caesareans, and this trend appears to be increasing. Prevention of urinary incontinence is one of the common reasons cited by women requesting elective caesareans. A large Australian study published in the British Journal of Obstetrics (2000) showed women's risk of urinary incontinence was not significantly reduced by elective caesareans. The incidence of problems, such as stress incontinence or prolapse was 42% in women who had one or more vaginal deliveries and 35% in women who'd had a caesarean delivery.  Opting for major abdominal surgery (caesarean) to avoid incontinence is not a reasonable choice at this time for most women. There are other serious complications of caesarean that need to taken into consideration. There is also evidence that if there is a slight protective effect from the first caesarean section it is lost with subsequent caesareans.

How does my bladder work?

The bladder is a hollow, muscular pump. It is slowly filled from the kidneys. Everyone has a different bladder capacity but you should be able to wait to go to the toilet until there is at least 300-400mls inside. Around the outlet of the bladder are a series of muscles called the pelvic floor muscles. These muscles relax when you are ready to go to the toilet and the bladder can then squeeze the urine out. It is these pelvic floor muscles that we especially target in urinary incontinence.

What do my pelvic floor muscles do?

Pelvic floor muscles preform an important function in women. They help to close off the bladder, bowel and vagina as well as keep the bladder, uterus and bowel in their correct place. Sometimes during pregnancy and/or after the birth the weakened pelvic floor muscles cause problems. These problems can present in a variety of ways. You may leak urine when you cough, sneeze, lift, laugh or exercise. You may also feel a sense of urgency when you want to empty your bladder. In some cases your muscles can’t support your bladder, uterus or your bowel and one or more of these organs may sag down into your vagina. This is commonly referred to as pelvic organ prolapse and it occurs in one in ten Australian women. A feeling of ‘something coming down’ may alert you to this. A weakened pelvic floor may also mean you are unable to control passing wind or you get a sense of urgency when you need to empty your bowel. Pelvic floor muscles also play an important role in sexual pleasure.

How is urinary incontinence treated?

Urinary incontinence is unlikely to go away by itself. The older women get the weaker pelvic floor muscles tend to get. After menopause this problem seems to escalate. It is very important for women to get the muscle strength back after each baby. There are both conservative and surgical treatments for incontinence depending on the severity of the symptoms and the impact it is having on women’s lives.

Conservative treatment generally consists of pelvic floor exercises. Pelvic floor exercises have been used quite successfully since 1948 and they basically re-tone the pelvic floor muscles so they do their job of closing off the bladder and holding the bladder and other pelvic organs in place (see fig 1). Sometimes vaginal cones are used as well as pelvic floor exercises. These are cone shaped weights (around 20gms to 100gms) and they are inserted into the vagina. The weights are useful for helping women become more aware of their pelvic floor and being able to retain cones of increasing weight lets women know they are making progress. The use of cones in conjunction with pelvic floor exercises has been shown to significantly reduce incontinence. Another treatment involves electrical stimulation of nerves with electrodes placed in the vagina or anus. Elevating devices, much like a tampon, are also used sometimes to help support the bladder neck and reduce incontinence. These can be useful for women who are incontinent at certain times like during exercise.

Surgical treatments are available when conservative treatment fails or the woman wants the problem completely dealt with. In surgical treatment the neck of the bladder is elevated and the opening of the bladder made more effective.

How do I do my pelvic floor exercises properly?

Pelvic floor exercises should be seen as an essential part of all women’s lives. Women, who have given birth, either vaginally or by caesarean section, need to be particularly vigilant. Recent studies have looked at intensive pelvic floor programs that target women most at risk (large baby, forceps or vacuum delivery) with good results. Pelvic floor exercises should be done gently throughout pregnancy and then more routinely after the first 24 to 48 hours following the birth. Pelvic floor exercise can also help with healing your perineum and preventing constipation after the birth. You can do these exercises anywhere!

The Continence Foundation of Australia recommends that you begin the exercises by sitting, leaning against a back support. You should squeeze the muscles around your front and back passage and you will feel them being pulled upwards and inwards. Try to hold this squeeze as if you were trying not to pass wind. You should feel the pelvic floor lift. The first time you do it though, especially following childbirth, you will find the movement is very small. It is important that there is no downwards movement of the pelvic floor when you are doing the squeeze and lift. You will feel the lower part of your tummy muscles gently pull in as you are doing the exercises. If you want to see the effect of the exercise then using a hand mirror can help you to see your pelvic floor working. Try to get into the habit of tightening, lifting and squeezing your pelvic floor muscles before every cough, sneeze and lift for the rest of your life. This is called ‘the knack’ and it will help protect your pelvic floor against further strain. If your pelvic floor muscles still feel weak following the birth then try crossing your legs and squeezing them tightly together before you cough or sneeze.

Pelvic floor exercises are a life long commitment and ideally should be done every day of your life! After you have given birth you should follow an exercise plan for about six weeks. These exercises should involve lifting up the pelvic floor and holding it as hard as possible. Combinations of slow and quick lifts are ideal. The Continence Foundation of Australia recommend that you do three sets of the following exercises each day: Firstly squeeze and lift your pelvic floor three times quickly with no rests and then squeeze, lift and hold the pelvic floor for three seconds, three times. These two types of exercises combined are one set and you should do three sets each day. You should also practice ‘the knack’ three times a day. This is when you squeeze up hard, hold and cough. You will find as you practice your pelvic floor exercises that you will be able to hold your squeeze for longer. After about three weeks when your perineum has recovered from the birth you may like to place two clean fingers in your vagina and squeeze hard, seeing how many seconds you can hold this squeeze. You should be able to feel the vagina squeezing your fingers and will be able to feel the improvement over the following weeks.

Remembering to do your pelvic floor exercise is one of the biggest challenges, especially when you have a new baby to take care of. Try to do a set of exercises (or use ‘the knack’) every time you do a certain thing. The Continence Foundation of Australia recommends you remind yourself to do your pelvic floor exercises at a certain time such as:

  • When you are going to the toilet
  • When you wash your hands
  • When you have a drink
  • When you change your baby
  • When you feed your baby
  • When you have a shower
  • A red dot or other sign can be used to remind you to do your exercises. You could put this near the toilet button, on the back of the bathroom door etc.
  • Ask your partner or a friend to keep reminding you!

Can urinary incontinence be prevented?

  • Regular pelvic floor exercises can prevent incontinence occurring and significantly reduce symptoms if they are already present.
  • Maintaining a healthy weight is also beneficial in reducing the incidence of urinary incontinence. It appears to reduce the strain on your pelvic floor.
  • Avoid heavy lifting or bouncing exercises for at least three months following the birth so your pelvic floor can recover. Gentle exercise like walking or swimming are ideal
  • Avoiding constipation is also important as it reduces the strain on your pelvic floor
  • Ensure you know what good bowel and bladder habits are

Good bladder habits

  • Drink at least two litres of fluid each day
  • Avoid drinking too many beverages with caffeine in them (cola, coffee, tea) as this can affect your bladder.
  • Try not to go to the toilet just in case (around 6-8 times each day is normal)
  • When you pass urine you should pass around 300-400mls each time.
  • Getting up once each night to go to the toilet is normal after you have had the baby but try not to go just because you have to get up to care for the baby

Good bowel habits

  • Have a diet high in fibre breads and breakfast cereals
  • Eat at least three pieces of fruit a day and drink fruit juices like orange juice or prune juice
  • Drink around 2 litres of water a day, especially if you are breastfeeding
  • Make sure you exercise daily
  • If you are constipated after these changes use a natural fibre supplement such a Metamucil
  • When you sit on the toilet try to raise your heels and relax your pelvic floor
  • When opening your bowels get a piece of toilet pater and support the front part of your pelvic floor with your hand to try and avoid it overstretching as you push
  • Try to push gently when opening your bowels. Hold the push and relax

Anal incontinence

As many as 6-10% of women experience leaking of faeces after giving birth. Anywhere between 13% and 20% of women pass wind without being able to control it. Damage to the muscles or nerves of the anus, during childbirth are probably the main cause of this. Women who have severe perineal tearing during childbirth are at greatest risk of this. The greatest risk of this kind of trauma is through forceps and vacuum births. Episiotomy, which involves a cut to the perineum, significantly increases the chance of women having severe trauma to the perineum. For many years doctors advocated routine episiotomy during childbirth to prevent severe trauma. We now have abundant research, much which was instigated by concerned midwives, to show that episiotomy rather than preventing trauma increases it and causes more problems with anal incontinence.

When to ask for help

You should ask for help if you notice leaking of urine at any time or need to rush to the toilet. Burning and stinging inside when you pass urine is also not normal. If you find you have to strain to pass urine you should also let someone know. There are many pads on the market that can reduce the inconvenience of incontinence and cater for all degrees of incontinence. Some are very slim and discreet.

Feelings

Urinary incontinence is a major problem that has a significant effect on women’s quality of life and the daily activities they are involved in. While it s physically limiting, incontinence also has a significant impact on women socially. It leads to some women having a restricted lifestyle. It can also lead to loss of self-esteem and feelings of anxiety, depression and helplessness. The hardest thing about incontinence is the silence that surrounds it as this further isolates women who suffer from it. The National Continence Helpline can help support women experiencing this problem and put them into contact with professionals and support groups that can help them. A large study of over 40 000 women in the community estimated that incontinence was prevalent in 12.8% of women aged 18-22, 36.1% of women aged 40-49 and 35.0% of women aged 70-74. It is important that women realise that it happens to women of all ages and in significant numbers for them not to feel they are alone. It is not, as is often thought, just a problem of old age.

National Continence Helpline: 1800330066 - 8am to 8pm Monday to Friday

Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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