Ask the Pharmacist

Q) I find I am leaking urine more and more often. It used to occur only when I had a forceful cough but now just standing up after driving for a while can cause it. Why is this happening and what can I do about it?

A) Any occasion that causes an accidental leakage of urine is referred to as an “urinary incontinent” episode, but there are several different types of incontinence that are differentiated by their cause. What is described here sounds like textbook stress incontinence (SI).

Stress incontinence is when urine leaks out due to a sudden increase in pressure on the bladder and urethra. This increase in pressure can be due to exertion (e.g. exercise, standing up, lifting something heavy) or an increase in intra-abdominal pressure (e.g. coughing, sneezing or laughing). It differs from its sister condition known as urge incontinence (also known as over overactive bladder which is characterized by a sudden “gotta go” sensation and the subsequent leakage of urine before they can find a bathroom) both in its treatment and as to the source of the problem.

In urge incontinence the issue is with the bladder, whereas SI is a urethral problem. In essence the musculature supporting the urethra is not strong enough to compensate for the sudden increase in pressure. These sphincter muscles can be stretched or weakened by a variety of causes but pregnancy and childbirth are two of the main culprits.

Stress incontinence is extremely common. It is far more common in women than it is in men and its incidence increases with age. By age 60, about one in three women find they sometimes leak urine and this number increases to 50% by the age of 65. Stress incontinence in men is almost always due to prostate cancer surgery, an injury to the pelvic nerve or damage to the tissues in that area. Most women with stress incontinence also have urge incontinence.

While incontinence is obviously not life threatening, it tends to have a massive impact on a person’s quality of life. It frequently leads to an individual forgoing activities they’d like to participate in leading to social isolation and it has been linked to anxiety, depression, sexual dysfunction and infections in the perineal region.

We’ve already discussed some risk factors for having stress incontinence (older age, history of pregnancy, being a female) but other factors that can make this more likely are being:

· Overweight
· A smoker
· Having a chronic cough
· A history of nerve injuries to the lower back
· Previous pelvic or prostate surgery

Treatment involves a combination of lifestyle changes, a number of “devices” or surgery. There are currently no drugs that are specifically designed to help with this (as opposed to overactive bladder disorder for which there are a bevy of medications that may help) but there are a few drugs designed for other disorders that may be helpful.

Among the lifestyle choices your doctor may suggest you attempt are:

· Quitting smoking
· Attempt to lose some weight
· Reduce your consumption of caffeine, carbonated drinks and alcohol
· Treat constipation, if that’s an issue
· Undergo bladder training- usually this involves keeping a diary as to how much you drink, when you urinate & when leaks occur. With training, your doctor may ask you to follow a schedule as to when you should urinate, and over time the intervals are gradually lengthened

The other main suggestion would be to learn how to perform Kegel exercises which is considered the mainstay of treatment. These exercises, also known as pelvic floor muscle exercises involve the contraction of the muscles that support the pelvic floor. It appears to be as effective as undergoing surgery in 50% of women who conduct these regularly without any of the risks. There are plenty of great physiotherapists in this area who can teach you how to identify the specific muscles and then contract them. You will usually be told to perform 8 to 12 contractions (held for 10 seconds or so) three times a day.

For women who are unable to perform these exercises, weighted cones that are inserted into the vagina or a device that is placed into the vagina and exerts a small electrical current that causes the muscles to contract can be tried.

Drugs that benefit some females include the application of vaginal estrogen (but not the pill form which may actually make things worse) used twice weekly (it may take up to three months for it to help) or the nerve pain drug duloxetine/ Cymbalta which can increase the resting tone & contraction strength of the urethral sphincter.

If none of these interventions help, then probably surgery will be suggested if the incontinent episodes are frequent and severe enough to warrant this. Surgical intervention usually works, particularly when it is combined with appropriate lifestyle changes.

Stress incontinence is a real pain to deal with but with a few lifestyle changes and some training, most people can get control of their symptoms and can get back to living life the way they’d like to. For more information about this or any other health related questions, contact the pharmacists