The document discusses urinary incontinence in women. It states that urinary incontinence, or the involuntary leakage of urine, is a common medical condition affecting about 35% of adult women globally. While most patients are women, poor education has led to ignorance about treatments. Modern advances now make the condition completely curable through various treatment options, improving patients' quality of life.

1. Dr. Shirish Yande
www.shirishyande.com email : shirishdyande@gmail.com
Urinary Incontinence in Women
A silent epidemic.
Urinary Incontinence or “Leakage of Urine” is a medical condition resulting
in inability to hold back urine. Despite the large number of patients suffering
from this disorder, the condition receives poor public attention and
education. While most of the patients are women, poor education results i n
ignorance about the various treatments and their potentials.
With constant advances in the medical knowledge has ensured that the
condition is now completely curable. Women patients must now realize that
they need not suffer from this embarrassing and debilitating condition
anymore. Today, with so many treatment options, this condition can be
controlled, leading to a marked improvement in the quality of life.

2. Content
What is Urinary Incontinence? ................................................................................................2
Incidence in India and worldwide .........................................................................................2
Medical reasons for Incontinence.........................................................................................2
Weakening of the pelvic floor...........................................................................................3
Intrinsic Sphincter Deficiency (ISD) ...................................................................................3
Factors that induce and aggravate Incontinence ...................................................................3
Types of Urinary Incontinence .................................................................................................4
Stress Urinary Incontinence .................................................................................................4
Urge Urinary Incontinence ...................................................................................................4
Overflow Incontinence ........................................................................................................4
Mixed Urinary Incontinence .................................................................................................4
Investigations .........................................................................................................................5
History................................................................................................................................5
Ultrasonography .................................................................................................................5
Urodynamics .......................................................................................................................5
Management Strategies and available options .........................................................................6
Behavioral / Muscle Therapy ................................................................................................6
Biofeedback ........................................................................................................................6
Medication .........................................................................................................................6
Surgery ...............................................................................................................................6
Treatment of Stress Urinary Incontinence ................................................................................6
Non-surgical Options ...........................................................................................................7
Electrical Stimulation .......................................................................................................7
Urethral Plugs .................................................................................................................7
Pessaries.........................................................................................................................7
Vaginal Weights ..............................................................................................................7
Surgical Options ..................................................................................................................7
Burch Colposuspension....................................................................................................7
Tension free Tapes ..........................................................................................................8
Bulking Agents ................................................................................................................8
Future trends .........................................................................................................................9
Epilogue .................................................................................................................................9
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3. What is Urinary Incontinence?
Urinary Incontinence refers to an involuntary leakage of urine due to any reason. For
anatomical reasons, women are more commonly affected by this condition than men. The
natural structure of female urethra makes it more susceptible for leakage of urine. Besides,
women undergo stress of pregnancy and labour, apart from being exposed to greater
hormonal changes than men. These factors make women more vulnerable for insults to the
pelvic floor.
Incidence in India and worldwide
Globally, about 35% of adult female population suffers from a general incidence of urine
leakage. These are surprisingly high numbers. These shocking statistics were also evident
amongst the urban population of Pune, where we surveyed a female population between
ages of 18 to 65 years, as they accompanied other patients in the Hospital Outpatients.
We interviewed 500 women in this group and found to our dismay that 31% said they had
experienced leakage of urine in clothes at some stage in life. 11% of the entire group
accepted that leakage of urine was a problem of severe magnitude that needed medical
help, although most had not approached a Doctor for solutions. This statistics highlight a
strikingly high incidence of urinary incontinence in our population and the shy attitude of
women that prevents them from seeking medical help.
Medical reasons for Incontinence
This is a brief introduction to the mechanism of Urinary Incontinence in women. In simple
words, leakage of urine occurs when the pressure inside bladder is greater than the one
inside the urethral tube. This generally does not occur during good health, since the control
muscle (Sphincter) contracts and keeps the urethra closed during the episodes of physical
stress such as coughing and sneezing.
Normal alignment of the Organs
supported by the Pelvic Floor
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Structure of the Pelvic Floor
Muscles

4. Incontinence is caused by malfunction of two important mechanisms.
Weakening of the pelvic floor
The muscles of the pelvic floor normally support organs such as bladder and the urethra (the
tube through which urine exits bladder.) Strength of pelvic floor keeps the urethra in
position even at time of physical stress. A weakened pelvic floor cannot hold the urethra in
its correct position and even a bout of cough or sneeze could cause a descent of urethra,
resulting in leakage of urine. This weakening may occur following multiple pregnancies,
childbirth injuries and some neurological conditions.
Intrinsic Sphincter Deficiency (ISD)
The sphincter muscles hold the urethra closed until it is time to urinate, when they relax
their grip and allow urine to flow. Women with ISD have weakness in the sphincter muscles
and cannot contain urine in the bladder. The urine thus leaks out during movements that
put pressure on the bladder.
Recent laboratory research suggests that women suffering from Stress Urinary Incontinence
have a deficiency of collagen, a substance that keeps the tissues together. The theory of
pelvic floor muscles producing a hammock has also gained acceptance in the medical
literature.
The Mechanism of Urinary Incontinence in Women
Factors that induce and aggravate Incontinence
As mentioned earlier, multiple vaginal deliveries and injuries will predispose women to
urinary incontinence. Advancing age and postmenopausal changes can reduce the strength
of pelvic floor muscles and fascial supports of the pelvic organs, leading to an increase in the
incidence of urinary incontinence in women. Chronic cough (and smoking) is known to
worsen the problem of incontinence for the obvious reasons. Obesity and other debilitating
illnesses too have similar effects on the control of the bladder. Stress Urinary Incontinence
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5. can also occur in young women before childbirth, although the incidence is quite low.
Types of Urinary Incontinence
Urinary Incontinence is categorized in four distinct types. Apart from these types, several
temporary and reversible reasons cause both stress and urge incontinence.
Stress Urinary Incontinence
Stress Urinary Incontinence (SUI) is the unintentional leakage of urine during physical
activities. Leakage of urine during coughing, sneezing, walking, exercising, shouting, bending
down, getting up from bed or seat all indicate Stress Urinary Incontinence. Patients of this
condition may have to use toilet more frequently during day to avoid accidental leakage.
Stress incontinence can affect women of any age. The condition is most often caused by
weakness in the pelvic floor resulting from multiple childbirths, pelvic surgery or
menopause. It is interesting to note that Stress Urinary Incontinence may also affect young
women without any of the above causes.
Urge Urinary Incontinence
Patients with Urge Urinary Incontinence may leak urine as soon as they feel a strong need to
urinate. While women with this condition have to rush to the toilet, they may not make it in
time. Unlike Stress Urinary Incontinence, Urge Incontinence is caused by an overactive
bladder rather than a weakness in the pelvic floor.
Overflow Incontinence
Patients affected by Overflow Incontinence have their bladder remaining full as they are
unable to evacuate it completely. This results in excess quantity of urine leaking away as an
overflow. This condition is usually associated with partial blockage to the passage of urine
for some reason, because of which the person is not able to empty the bladder.
Mixed Urinary Incontinence
This medical term describes a combination of both stress and urges incontinence. These
conditions often coexist and are indistinguishable from each other based on the patient’s
symptoms.
Fistulas
Abnormal connections between the bladder and the vagina (such condition can occur rarely
as a complication of surgery over these organs) can produce leakage due to bypassing of the
normal control mechanism of the urethra.
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6. Traces of Urodynamics Investigation
View of Urodynamics Laboratory
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Investigations
History
A thorough study of patient’s clinical history is very important to determine the exact type of
incontinence and its severity. This should also include a note of effect of incontinence on
the patient’s lifestyle. This study facilitates the correct choice of treatment for that particular
patient.
Examination
Thorough clinical examination will confirm the presence and type of incontinence. The
examination will also note any prolapse of pelvic organs and other associated abnormalities.
Ultrasonography
Ultrasonography of urinary tract confirms the normal anatomy of pelvic organs as well as
completeness of bladder evacuation while emptying.
Urodynamics
The clinical interrogation, examination and imaging may leave some questions unanswered.
For instance, stress and urge incontinence may coexist and distinguishing one from another
may not be easy. Besides, the bladder function may be weak and may not empty completely.
These situations lead to difficulties in advising surgical treatment for incontinence.
Clearly another objective test is necessary to confirm the correct diagnosis in these patients.
Urodynamics is a test that investigates flow and pressure of urinary system. Urodynamics
investigation is generally advisable before a surgical treatment is considered.
This sophisticated investigation involves passage of catheters in the bladder and making
accurate measurement of bladder pressure, urinary flow etc. Urodynamics investigation,
although invasive, has made diagnosis of various conditions more accurate, thus allowing
precise choices of management for every individual.

7. Management Strategies and available options
Behavioral / Muscle Therapy
Behavioral / Muscle therapy teaches patients various ways to control their bladder and the
muscles involved in urination. The first line therapy is usually Kegel exercises, which are used
to strengthen the pelvic muscles. Besides, lifestyle changes such as modifying water intake
and avoiding caffeine beverages also help to a large extent. Other methods can be used
alone or in combination with the following therapies.
Biofeedback
This process works by improving patient’s awareness of the (otherwise unperceivable)
bladder and muscle activities and help gain control over their bodily function by making
voluntary effort to control these activities.
Medication
Treatment of urge incontinence is largely medical. Drugs such as Oxybutynine, Solifenacin
and Tolterodine control overactivity of the bladder. These drugs are marketed under various
brand names and are available freely in the market. These drugs should be taken only under
medical supervision and it is necessary to take them for a very long period.
Very recently Serotonin related drugs have shown promise in improving contracti le capacity
of the sphincter muscles. These drugs are marketed in India only recently, hence the extent
of benefit as well as long –term effects of these formulations is yet to be established.
Such medication can potentially augment the closure of the urethral sphincter.
However Stress Urinary Incontinence (SUI) does not commonly respond to drug therapy.
Only in some cases where SUI is associated with hormone deficiency, it may be treated with
hormone replacement therapy such as estrogen vaginal cream. For patients who do not
respond to these drugs may need endoscopic injections in the bladder wall.
Surgery
In extreme and intractable cases, surgery to increase the bladder capacity (Augmentation
Cystoplasty) may also be necessary. Treatment of overflow incontinence is mainly directed
to relieve blockage of the urinary passage. Fistulas usually require surgical correction and are
associated with excellent results.
Treatment of Stress Urinary Incontinence
Non-surgical treatment options are of four distinct types. These treatments have a limited
success but can be offered to patients who are either frail to undergo surgical correction or
have a very mild incontinence. The three surgical options are mentioned below.
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8. Non-surgical Options
Electrical Stimulation
Electrical stimulation restores the activities of the muscles that have weakened as a result of
injury or fatigue. Pelvic floor muscles can potentially be strengthened by electrical
stimulation.
A number of newer methods and devices have been proposed to control the leakage of
urine in women.
Urethral Plugs
These Urethral Plugs may temporarily close off the urethral opening and prevent leakage of
urine.
Pessaries
A Pessary inside the vagina can raise the urethra and suspend it in the raised position as
long as it is in place.
Vaginal Weights
These weights can be held inside the vagina by sustained contraction of the relevant
muscles.
Surgical Options
Where conservative treatment fails or when the leakage becomes bothersome, patients will
require surgery to manage their SUI.
With advancement in technology, surgery has become minimally invasive and requires
limited hospitalization. A number of procedures have evolved in the past 60 years to t reat
the condition of SUI.
Although large numbers of operative procedures are available to treat this condition, the
following three operations are performed commonly in modern medicine.
Burch Colposuspension
This is an established surgical procedure in modern
Urology and has stood the test of time. Although very
effective, it involves a cut on the abdomen and stay in
the hospital for 3 to 5 days.
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9. 8
Tension free Tapes
Tension Free Tapes have become popular over the past
15 years for surgery to correct Urinary Incontinence. This
surgery involves insertion of a tape made of Prolene
Mesh beneath the Urethra through a small vaginal
incision. During surgery, the mesh is positioned in the
correct place.
There are a number of variations of this procedure, all of
which are simple to perform. The tapes are slightly
expensive but these procedures ensure least patient
Tension free Tape in place Tension Free Tape in place : an Alternative Route
discomfort and a very short hospital stay.
The tapes are commonly known as TVT, TVTO, TVT Abbrevo etc. They have caused a
revolution in the surgery for SUI in women.
Bulking Agents
These are useful in old fragile women where the muscle tissue has become very weak.
Although not as effective as a tape, it can largely control the problem of leakage in women,
who are not fit to undergo even a small operating procedure.

10. 9
Future trends
With the current level of technology, surgery for Stress Urinary Incontinence for women has
evolved into a minimally invasive procedure for the patients. These surgeries are simple to
perform and affordable to the Indian population. The modern Tapes are shorter in length
and cause even less discomfort to the patient. Advances in the medical field continue to
search for treatments that are even less invasive, more effective and affordable. In the near
future, insertion of tapes may get replaced with injections behind the pubic bone, which can
potentially have the same effect as a tape.
Epilogue
Worldwide, Urinary Incontinence remains a common problem for women. Its magnitude in
Indian population is very large and significantly affects the quality of life. Among women, the
real problem appears to be lack of awareness about the treatment options. I f correctly
investigated and treated, this condition is completely curable for life. The present challenge
is to create and spread the awareness about this widespread medical condition and its
treatment to the society at large.