Urinary incontinence describes the involuntary loss of urine which is estimated to affect up to 20% of women, the incidence rising with advancing age. Incontinence occurs when the sphincter muscle of the bladder does not close due to poor bladder neck support causing loss of urine on coughing, sneezing or physical activity, this being known as stress incontinence. This is caused by damage to the muscles and connective tissues of the pelvis following childbirth and often aggravated by lack of oestrogens that occur at menopause or with chronic cough and constipation. Incontinence can also occur when the bladder muscle contracts independent of voluntary control as in the case of an over-active bladder causing urge, urgency or urge incontinence. This may be caused by repeated bladder infections (cystitis) producing a small capacity bladder. The 2 conditions can coexist together this being known mixed stress and urge incontinence.
Urinary incontinence is not only a cause of embarrassment but can also interfere with every day activities affecting the quality of life and causing social isolation. Urge incontinence is managed by medical treatment such as anticholinergic agents (Ditropan) which work by causing relaxation of the bladder muscle. Oestrogen therapy either locally (Vagifem) or systemically as in HRT can be administered to improve symptoms. In cases of stress incontinence associated with prolapse, a surgical approach to support the urethra and bladder neck should be considered. The preferred treatment is to insert a tension-free vaginal tape (TVT) below the urethra and bladder neck which will provide additional support in times of sudden increases of intra-abdominal pressure such as coughing. The TVT is a minimally invasive procedure with the tape being inserted by 2 needles via a small incision in the vagina to support the urethra and bladder neck. The needles travel behind the pubic bone to emerge through the lower abdominal wall. The tape is inserted without any tension so that there may be no voiding difficulties post operatively. The patient is discharged 48 hours after the procedure which is often done under a spinal block. The TVT is very successful in treating stress incontinence with a greater than 90% success rate after 5 years. In cases of mixed incontinence, medical treatment should always be given before any surgical treatment is considered.