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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