Pres­sure leaks

Ir­re­spec­tive of whether the amount of urine leaked is small or large, in­con­ti­nence can be dis­tress­ing and em­bar­rass­ing.

The Star Malaysia - Star2 - - HEALTH - By Dr MIL­TON LUM

THE kid­neys pro­duce urine which passes through the ureters to en­ter the blad­der, a hol­low and dis­ten­si­ble or­gan that sits on the pelvic floor that has a ham­mock­like struc­ture com­pris­ing mus­cles and con­nec­tive tis­sue. The pelvic floor sup­ports or­gans like the blad­der, in­testines, and the uterus in fe­males and has a nar­row gap through which the ure­thra, rec­tum, anus, and vagina tra­verse.

The urine ex­its the blad­der through the ure­thra. This oc­curs when both the blad­der’s in­ter­nal and ex­ter­nal sphinc­ters are opened. The con­trol of the for­mer is in­vol­un­tary and the lat­ter, which is a cir­cu­lar mus­cle around the ure­thra, vol­un­tary. Al­though there is in­di­vid­ual vari­a­tion in blad­der ca­pac­ity, it is gen­er­ally ac­cepted that the ca­pac­ity in the adult is about 500 ml. The de­sire to uri­nate oc­curs when the blad­der vol­ume is about 300 to 350 ml. As the blad­der con­tin­ues to fill, the de­sire to uri­nate in­creases and be­comes more dif­fi­cult to ig­nore.

The blad­der can store a large vol­ume of urine with­out much in­crease in in­ter­nal pres­sure. When there is an in­crease in in­tra-ab­dom­i­nal pres­sure, e.g. cough­ing, sneez­ing, laugh­ing, heavy lift­ing, ex­er­cis­ing, or chang­ing po­si­tion, this is usu­ally trans­mit­ted equally to the pelvic floor and or­gans, in­clud­ing the blad­der.

How­ever, when there is weak­ness of the pelvic floor mus­cles and/or ex­ter­nal sphinc­ter, or mal­func­tion of the ex­ter­nal sphinc­ter, an in­vol­un­tary leak­age of urine can oc­cur when the in­tra-ab­dom­i­nal pres­sure is in­creased. This is be­cause the ex­ter­nal sphinc­ter can­not stay closed to pre­vent urine flow from the blad­der, and this is called stress uri­nary in­con­ti­nence (SUI).

SUI has to be dis­tin­guished from urge in­con­ti­nence, which is due to over­ac­tive blad­der mus­cles that leads to a strong urge to uri­nate even when there is lit­tle urine in the blad­der.

There may be sit­u­a­tions in which there is both SUI and urge in­con­ti­nence. There are also other causes of in­con­ti­nence like prostate prob­lems and nerve dam­age.

In short, uri­nary in­con­ti­nence is tan­ta­mount to loss of blad­der con­trol. The symp­toms can range from mild leaks to un­con­trol­lable ones. It can hap­pen at any age but is more com­mon with in­creas­ing age.

Ir­re­spec­tive of whether the amount of urine leaked is small or large, in­con­ti­nence can be dis­tress­ing and em­bar­rass­ing.

Risk fac­tors

There are sev­eral fac­tors that in­crease the risk of SUI – which is the most com­mon type of uri­nary in­con­ti­nence in women.

Preg­nancy and child­birth in­crease the risk of SUI. The in­creas­ing weight of the de­vel­op­ing baby in preg­nancy ex­erts in­creased stress on the pelvic floor. Fur­ther­more, the hor­mone, re­laxin, which is pro­duced in preg­nancy, soft­ens the pelvic floor mus­cles in prepa­ra­tion for child­birth. These changes re­sult in SUI in about half of all preg­nant women.

Dur­ing vagi­nal de­liv­ery, the pelvic floor can get stretched and bruised. This can have sub­se­quent ef­fects on the func­tion­ing of the pelvic nerves and mus­cles. A Dan­ish study of more than 2,000 women re­ported that the risk of de­vel­op­ing uri­nary in­con­ti­nence was in­creased three times in women who had a per­ineal tear or epi­siotomy.

SUI which de­vel­ops dur­ing preg­nancy or af­ter child­birth usu­ally im­proves with time. How­ever, it may re­cur and treat­ment may be re­quired.

Af­ter the ces­sa­tion of pe­ri­ods (menopause), oe­stro­gen lev­els are de­creased con­sid­er­ably. As the pelvic floor is oe­stro­gen de­pen­dent, the mus­cle pres­sure around the ure­thra is weaker af­ter menopause. This, com­bined with the de­creased elas­tic­ity of the ure­thra with con­se­quent in­abil­ity to close com­pletely, in­crease the like­li­hood of SUI.

Post­menopausal women are also more likely to be over­weight and have had a hys­terec­tomy, both of which in­crease the risk of SUI. Hys­terec­tomy is an op­er­a­tion in which the uterus is re­moved and can lead to dam­age of the pelvic floor. There is more pres­sure on the ab­domen in the over­weight, with con­se­quent in­crease in pres­sure on the pelvic floor. A Bri­tish study re­ported that over­weight women were twice as likely to have SUI when com­pared to some­one of nor­mal weight.

Chronic cough, which is more com­mon in smok­ers, in­creases the pres­sure on the pelvic floor, thereby weak­en­ing its mus­cles and in­creas­ing the risk of SUI.

Some medicines can af­fect the pelvic floor, e.g. some high blood pres­sure medicines, an­tide­pres­sants, seda­tives, and mus­cle re­lax­ants.

The blad­der’s sphinc­ter mus­cle can be dam­aged by pelvic frac­ture, blad­der neck surgery or rad­i­cal prosta­te­c­tomy in men. And there are some rare in­di­vid­u­als who have an in­her­ited weak­ness of the pelvic floor mus­cles.

Clin­i­cal fea­tures

Pa­tients with SUI com­plain of an in­vol­un­tary loss of urine when cough­ing, sneez­ing, laugh­ing, heavy lift­ing, ex­er­cis­ing, chang­ing po­si­tion, or dur­ing sex­ual in­ter­course.

The phys­i­cal ex­am­i­na­tion will in­volve a gen­eral, ab­dom­i­nal and rec­tal ex­am­i­na­tion, in­clud­ing a pelvic ex­am­i­na­tion in women and gen­i­tal ex­am­i­na­tion in men.

The find­ings may in­clude bulging of the blad­der or ure­thra into the vagi­nal space (cys­to­coele or ure­thro­coele) and/or uter­ine pro­lapse. SUI can be tested by get­ting the pa­tient to cough, strain, or stand with a full blad­der.

The usual in­ves­ti­ga­tions in­clude an ab­dom­i­nal and/or pelvic ul­tra­sound and uri­nal­y­sis and/or cul­ture to ex­clude uri­nary tract in­fec­tion.

Other in­ves­ti­ga­tions in­clude check­ing the resid­ual urine in the blad­der af­ter void­ing and a pad test which in­volves weigh­ing a pre-weighed san­i­tary pad af­ter ex­er­cise to de­ter­mine the amount of urine loss.

Other in­ves­ti­ga­tions that may be done in­clude x-rays of the uri­nary tract af­ter in­tra­venous in­jec­tion of dye, i.e. in­tra­venous pyel­o­gram (IVP), uro­dy­namic stud­ies, in­spect­ing the in­side of the blad­der with a te­le­scope-like in­stru­ment (cys­toscopy), and rarely, elec­tromyo­g­ra­phy to check on the mus­cle ac­tiv­ity.

Pa­tients may also be asked to keep a record of the times of void­ing and leak­ing of urine.


There are four man­age­ment modal­i­ties avail­able, i.e. life­style changes, pelvic floor ex­er­cises, medicines, and surgery. The modal­i­ties may be used alone or in com­bi­na­tion The choice(s) are in­flu­enced by the sever­ity of the prob­lem and the ex­tent to which it in­ter­feres with daily life.

Life­style changes in­clude smok­ing ces­sa­tion; weight re­duc­tion, if over­weight; good di­a­betic con­trol; void­ing more of­ten to re­duce the amount of urine that leaks; en­sur­ing reg­u­lar bowel move­ments to avoid con­sti­pa­tion, which can worsen SUI; avoid­ing ex­ces­sive fluid in­take, caf­feine and al­co­hol (which can stim­u­late the blad­der), and food and drinks that may ir­ri­tate the blad­der, e.g. car­bon­ated drinks; and avoid­ing heavy lift­ing, run­ning, or jump­ing.

Pelvic floor mus­cle train­ing (PFMT), of­ten called Kegel ex­er­cise, strength­ens the pelvic floor mus­cles, par­tic­u­larly the ure­thral sphinc­ter. It in­volves al­ter­nate con­trac­tion and re­lax­ation of the pelvic floor mus­cles. The chal­lenge for many women is to iden­tify the mus­cles. This can be done by in­sert­ing a fin­ger into the vagina and squeez­ing the sur­round­ing mus­cles. The vagina would tighten and the pelvic floor moves up­ward. Upon re­lax­ation of the mus­cles, the pelvic floor would re­turn to the start­ing po­si­tion.

Men can also do PFMT. The pelvic floor mus­cles can be iden­ti­fied dur­ing void­ing and at­tempt­ing to stop it com­pletely once urine starts to flow. The mus­cles that tighten up are the pelvic floor mus­cles.

PFMT can be done at any time with­out other per­sons notic­ing it. One should try and do PFMT as ad­vised by the doc­tor. If done reg­u­larly, an im­prove­ment (less fre­quent leak­age) will be no­tice­able within four to 12 weeks.

A re­view of tri­als pub­lished in the Cochrane data­base found that “pelvic floor mus­cle train­ing (mus­cle-clench­ing ex­er­cises) helps women with all types of in­con­ti­nence, al­though women with stress in­con­ti­nence who ex­er­cise for three months or more ben­e­fit most.”

The re­view re­ported “sup­port for the wide­spread rec­om­men­da­tion that PFMT be in­cluded in first-line con­ser­va­tive man­age­ment pro­grammes for women with stress, urge, or mixed, uri­nary in­con­ti­nence.”

Dif­fer­ent types of medicines may be pre­scribed in SUI. They in­clude an­tibi­otics for uri­nary tract in­fec­tions and top­i­cal oe­stro­gens in post-menopausal women. The lat­ter im­proves uri­nary fre­quency and ur­gency as well as the tone and blood sup­ply of the ure­thral sphinc­ter mus­cles. How­ever, whether oe­stro­gens im­prove SUI is con­tro­ver­sial. Surgery is rec­om­mended for SUI in se­lected pa­tients, usu­ally af­ter PFMT has been at­tempted. Var­i­ous sur­gi­cal tech­niques are avail­able. They in­clude an­te­rior vagi­nal re­pair; col­po­sus­pen­sion; col­la­gen in­jec­tions; ten­sion free vagi­nal tape; and vagi­nal sling pro­ce­dures.

The gy­nae­col­o­gist or the urol­o­gist, who are the spe­cial­ists who per­form such pro­ce­dures, will dis­cuss with the pa­tient the pros and cons of the dif­fer­ent tech­niques.

There are risks of com­pli­ca­tions in surgery and they in­clude sur­gi­cal site in­fec­tions, uri­nary tract in­fec­tions, vagi­nal in­fec­tions, ero­sion of the sur­gi­cally placed ma­te­ri­als, and painful sex­ual in­ter­course. Al­though un­com­mon, com­pli­ca­tions can and do oc­cur.

Fail­ures of treat­ment are more com­mon in pa­tients who have con­di­tions that ham­per heal­ing or surgery, have other prob­lems of the gen­i­touri­nary tract, or whose surgery failed pre­vi­ously.

Per­form­ing PFMT may help pre­vent symp­toms and do­ing it dur­ing and af­ter preg­nancy can de­crease the risk of de­vel­op­ing SUI af­ter child­birth. n Dr Mil­ton Lum is a mem­ber of the board of Med­i­cal De­fence Malaysia. This ar­ti­cle is not in­tended to re­place, dic­tate or de­fine eval­u­a­tion by a qual­i­fied doc­tor.

The views expressed do not rep­re­sent that of any or­gan­i­sa­tion the writer is as­so­ci­ated with.

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