Regaining control of a wilful bladder

PUBLISHED : Tuesday, 13 September, 2011, 12:00am
UPDATED : Tuesday, 13 September, 2011, 12:00am


Laughing comes spontaneously for most people. But for 59-year old retiree housewife Queenie Lau, it's a cause for embarrassment - she leaks urine when she laughs.

Lau has urinary incontinence, which she thinks was brought on by her habit of holding her bladder for long periods.

She is not alone. A survey commissioned by the Women's Health Alliance of Hong Kong Primary Care Foundation earlier this year found that one in three women surveyed had experienced urinary incontinence. Like Lau, 80 per cent of respondents said that the problem occurred when they sneezed or laughed out loud.

According to the Hong Kong Continence Society, up to 70 per cent of women with incontinence suffer in silence for reasons such as embarrassment, belief that the condition will go away eventually, or the misconception that incontinence is normal for women, the sick and the elderly. In fact, incontinence can happen to anyone - although it is much less prevalent in men - and is highly treatable with success rates of up to 60 per cent.

Simply put, a person with the condition leaks urine involuntarily. 'We don't need fancy tests to confirm incontinence. As long as the patient complains that urine comes out involuntarily through the urethra, she is having urinary incontinence,' says Dr Ida Mah of the Hong Kong Urology Clinic.

The average adult bladder can hold up to 550ml of urine and relies on its sphincter and detrusor muscles to fill and store urine. The sphincter muscle controls the flow of urine out of the body, while the detrusor muscle in the bladder wall must stay relaxed to allow the bladder to expand to accommodate urine.

Most people will feel the urge to pee when there is about 200ml of urine in the bladder. Those with incontinence, however, may leak urine at any time. In patients with stress incontinence, this is due to weaknesses in the sphincter muscles and the pelvic muscles that support the bladder and urethra. Urine may leak out during activities that place pressure on the abdominal area, such as laughing, coughing, sneezing or running.

'The underlying cause is usually pelvic floor laxity associated with childbirth,' Mah says. 'Women who have repeated vaginal deliveries especially with big babies are at increased risk. Obesity is also a risk factor.'

The other main type of incontinence is urge incontinence, which occurs as a result of involuntary bladder muscle contractions stemming from neurological problems or bladder irritation. 'The patient will complain of frequent urination and urgency of urination. When she feels the need to go, she has to go immediately. If she tries to hold her bladder, she may leak urine before she manages to reach the toilet,' says Mah.

Incontinence is treated according to its type. For stress incontinence, prevention is better than cure. Mah advises all women to practise pelvic floor exercises called Kegels soon after delivery, while those who are already experiencing incontinence can do so under the guidance of a continence nurse.

Surgery is an option for patients who do not see an improvement in their condition despite doing pelvic floor exercises. The most common is the tension-free vaginal tape (TVT) procedure, where a mesh tape is placed under the urethra to act as a sling to support it. The tape is inserted through small incisions in the vaginal wall and abdomen, and does not require stitches to keep it in place. 'TVT is a minimally invasive surgery with a success rate of more than 90 per cent,' Mah says. 'The patient only needs to stay in hospital for a day or two and can resume her daily activities soon after discharge.'

For those with urge incontinence, medication is the mainstay of treatment. Drugs are prescribed alone or in combination with others to relax the bladder muscles and prevent involuntary bladder contractions. In severe cases, botox may be injected into the bladder muscles to paralyse them. However, the effect lasts for less than a year in most patients.

Bladder retraining under the supervision of a continence nurse may also help. Patients will be taught to develop a schedule of times when they should try to urinate, and consciously try to delay urination between these times. The voiding interval is then gradually increased, until the patient is able to control urination and limit it to once every three to four hours.

Lifestyle changes play as big a role as drugs, surgery and Kegels in managing incontinence. Avoid alcohol and coffee as they have a diuretic effect, leading to increased urine production. Losing those extra pounds can also help, as the added weight places more pressure on the abdomen. And if you're a smoker, kick the habit. Smoking is a known bladder irritant, while the chronic smoker's cough can damage pelvic floor muscles. With a few smart lifestyle choices, and a good urologist, you'll soon regain control of your bladder.

How to do Kegels

Kegel exercises - named after its inventor Dr Arnold Kegel, the late assistant professor of gynaecology at the University of Southern California School of Medicine - strengthen the pelvic floor muscles, which support the uterus, bladder and bowel. You can do them discreetly at any time, even when you're pregnant. Here's how:

1. Find the right muscles

An easy way to isolate the muscles is to try to stop the flow of urine when you're in the toilet. Once you've succeeded, relax and empty your bladder completely. Do not make it a habit of starting and stopping your urine stream, as this can weaken the muscles and cause urinary tract infection due to retained urine in the bladder.

2. Repeat

While seated or lying down, contract your pelvic floor muscles, hold for five seconds, then relax for five seconds. Repeat this for up to five times, then try to increase the intervals to 10 seconds each. Remember to breathe as you do this, and keep your abdominal, thigh and buttock muscles relaxed.

3. Make it a habit

Aim for at least three sets of 10 repetitions daily, and do it at fixed times throughout the day; for example, during every commercial break when you watch television.