06th Aug 2019
One in three women will experience urinary incontinence at some point in her life. With that in mind, we spoke with Aoibhín McGreal, a Clinical Specialist Physiotherapist in pelvic floor dysfunction at Beacon Hospital, about what urinary incontinence is; how it can be treated, as well as the impact of the condition on day-to-day life
Urinary incontinence is a lot more common than you think. Whether it’s a little pee leaking out when you laugh or sneeze, or a more urgent dash to the loo, urinary leakage affects one in three women at some point during her lifetime.
While it’s more common among women who are pregnant or post-natal, urinary incontinence can happen to any woman, at any age, at any time. The good news is 70% of these cases are treatable with physiotherapy.
We recently spoke with Aoibhín McGreal, a Clinical Specialist Physiotherapist at Beacon Hospital, about the condition; how it impacts a woman’s day-to-day life and most importantly, how to treat it.
What is urinary incontinence?
“Urinary incontinence is urinary leakage or involuntary loss of urine,” Aoibhín McGreal says. “There are different types – the most common ones we speak about are stress and urge incontinence.
“With stress incontinence, leakage occurs in response to what we call increased ‘intra-abdominal pressure’; so for example, laughing, coughing, sneezing and exercising.
“And then there’s urge incontinence, which is a sudden, strong, uncontrollable urge; when they get an urge to go but can’t get to the toilet on time.
“While these symptoms are really common, it shouldn’t be accepted as being normal. They can definitely do something about it…”
“You can have one or the other, or a bit of a mixture of both,” Aoibhín says. “Once a patient describes her symptoms, we generally have an idea of which type we are aiming to treat”.
There are various reasons why a woman might develop urinary incontinence. The most common factor is pregnancy, both pre and post-natal (which we’ll touch on later), as well as menopause; obesity; constipation; different surgeries, such as a hysterectomy; and reduced mobility, which might prevent them from getting to the toilet in a hurry.
Impact on day-to-day life
The impact of urinary incontinence can vary from woman to woman. “I meet women reporting symptoms ranging from one leak every two weeks, to several leaks per day,” says Aoibhín.
“We use an outcome measure to establish how bothersome these symptoms are, and we ask them to rate it from zero to 10. There are some women who find it extremely difficult to live with and others who put up with it, to an extent.
“For some women, it will prevent them from exercising, it will prevent them from socializing. So in that way, in my opinion, it’s a public health concern.
“While these symptoms are really common, it shouldn’t be accepted as normal. It’s definitely something that can be treated…”
“If it’s impacting a woman’s ability to socialize; to get up and dance at a wedding; to go for a jog or a walk with friends, well then it can have a major impact on her confidence and ultimately her mental health.
“It can also impact her relationship,” Aoibhín explains. “She might be avoiding having sex due to embarrassment or concern that there’s an odour, or a fear of leaking.
“What we want to get across is that, while these symptoms are really common, it shouldn’t be accepted as being normal. They can definitely do something about it; urinary incontinence can be very effectively treated,” she says.
What is the pelvic floor?
“Your pelvic floor muscles are a group of muscles that attach to the inner rims of the pelvis. They attach from your pubic bone all the way back to your coccyx (tailbone), and they’re also attached to your seat bones and up inside the pelvis,” Aoibhín says.
While the pelvic floor is often described as a sling or a hammock, Aoibhín says they’re actually more like a basin in shape, because they take up the whole underneath of the pelvis. What’s more, the urethra (the tube from the bladder), the vagina and the rectum all pass through the pelvic floor.
“The pelvic floor is involved in bladder and bowel control; bladder and bowel emptying, sexual function, as well as being involved in working with your diaphragm and abdominal muscles when you’re moving, breathing and lifting – it is involved in all of that,” she says.
It is when these muscles are not functioning properly that urinary incontinence can develop.
Many (though not all) women who experience urinary incontinence will do so around pregnancy. Aoibhín explains, “Pregnancy alone can weaken the pelvic floor with the weight of the growing baby. But then, obviously, with the vaginal delivery, there is an increased risk due to the stretching, and maybe even damage to the pelvic floor and connective tissues”.
What’s more, incontinence during pregnancy is quite common because you’ve got the weight of the growing baby putting pressure on the bladder and its supporting muscles; as well as hormonal changes which cause increased urinary frequency.
Pelvic floor exercises
There are various exercises you can do to strengthen your pelvic floor muscles to prevent incontinence happening. Aoibhín likens them to the squeezing sensation you do when stopping the flow of urine or stopping yourself from passing wind. But, it’s important to learn how to tighten/release those muscles without tensing up your legs, bum and stomach in the process.
It is also extremely important to ensure that theses muscles are fully relaxed after each ‘squeeze’ because overactive or ‘tight’ pelvic floor muscles can lead to problems too.
That being said, the specific exercises you need depend on what type of urinary incontinence you have. Aoibhín says, “It’s a real skill that people have to learn. One in three women will actually do it wrong with verbal instruction alone.
“If women are having any symptoms of pelvic floor dysfunction,” she says, “then they absolutely should see a women’s health physio / pelvic health physio. There’s no point doing lots of exercises with the incorrect technique – you’re just not going to get the results”.
“The average bladder should hold 300 to 600 hundred millilitres; if you’re holding over 800 millilitres at a time, that’s too much…”
“When we assess a person who is leaking when they cough, we might give them a very different program to the person who leaks after they’ve run the first 10 miles of a marathon,” Aoibhín says.
“If you feel like, ‘Oh, I’ve done my exercises, but I’m still leaking’, you may need a more functional program to suit your level of fitness, and what causes you to leak,” she adds.
For example, some people will have better results if they do their exercises standing with their feet apart; others notice a difference if they do the exercises on one leg. For that reason, it’s important to consult with a women’s health physio, rather than trying to tackle the issue alone.
The physio assessment
Speaking about the assessments, Aoibhín says, “We generally advise a vaginal examination to assess the pelvic floor as we can then grade the strength, tone and endurance of the muscles”. Not only does she test your muscles ability to contract, but also their ability to relax.
“I see a lot of women with what we call ‘overactive’ pelvic floor muscles, where they actually are holding the muscles quite tight and tense all the time. It’s a bit like having your shoulders up around your ears – you need to be able to let them down,” she explains.
“When we do an assessment, we can teach women how to accurately recruit the muscles, and then relax them.
“Here in the Beacon, we also use ultrasound so that women can actually watch their pelvic floor on-screen. If you’re learning how to dance, often you’d watch in the mirror to make sure you’re doing it right – but when it comes to the pelvic floor, it’s very hard to do that.
“So that’s why we use ultrasounds. It is a lot easier to correct your technique when you can see what the muscles are doing. Ultrasound can also be very useful for women who do not wish to undergo a vaginal examination,” Aoibhi?n says.
If conservative treatments, such as pelvic floor exercises don’t work, there are other options out there; from medication to surgery (though it’s important to note these alternative treatments are not generally the first port-of-call).
“There are certain types of pessaries, which are silicone or PVC rings that can be inserted vaginally to support the bladder neck,” Aoibhín says, “and they can prevent leakage (these are also used for prolapse). There are also support shorts that some women wear and find that they help.
“A lot of women will see electrical stimulation devices online, and some of them are very good. But I would just reiterate that, before they spend their money on a certain device, have an assessment so you can see where you’re at and what device (if any) may be more likely to help,” she adds.
“Surgery wise – readers might be aware there’s a debate around the use of vaginal mesh at the moment, and mesh is currently under review by the HSE due to reports of complications such as pain.
“I have met many women who have undergone mesh surgery – for example, mid-urethral sling – and have found it to be excellent,” Aoibhín says.
“I think there needs to be a conversation with the individual woman. If she has tried conservative measures; she has done her exercises with a physio; she has tried a pessary and it’s not working, then I think we have to take a balanced view.
“Be aware that all surgical procedures carry risk, but if there are women who remain symptomatic despite conservative treatment, and it’s impacting on their life; if they can’t exercise or do the things they want to be doing; then surgery may well be an excellent option for some of those women. It’s not the first thing that they go and do – but the option should be there”.
How long should I hold my pee?
“The average bladder should hold 300 to 600 hundred millilitres; if you’re holding a litre at a time, that’s too much,” says Aoibhín.
“If you’re drinking two litres of fluid a day, you should be going [to the loo] about seven times and once at night (this can increase slightly as you’re getting older). On average, emptying 300 millilitres from your bladder every two hours during the day will be normal,” she says.
“But if you’re only drinking 100 millilitres of water a day, that’s not going to happen. Similarly, if you’re drinking four litres a day, you’re probably going to need to go more often than that. That’s why we tend to ask women who are symptomatic to measure what they’re passing so we can actually see what the bladder is up to”.
What’s more, Aoibhín says if your bladder is overactive (ie. you are emptying small amounts frequently), you need to cut down on things that irritate it; such as caffeine, alcohol, carbonated drinks, citrus fruit. It’s important to keep the balance healthy and regular, avoiding constipation, and then start what we call ‘bladder training’, where you start trying to get the bladder to hold a little bit more.
Talk to your GP and/or physio
Urinary incontinence can be treated, so even if it only bothers you from time to time, say it to your GP. “Remember that this is really common, you’re not going to surprise your GP by telling them this. Doctors are used to hearing about these symptoms. Sometimes changes to bladder habit can indicate other medical conditions so speaking to your GP about it in the first instance is a good idea..
If you are not automatically referred to a women’s health physiotherapist, you could ask your doctor to refer you or you can self-refer.
“There are some women who discuss this with all their friends and put up with it. There are others who don’t discuss it at all and put up with it. Ideally, we don’t want any women to put up with it. We want them to address it, and we can help them with that.”
Aoibhín McGreal is a Clinical Specialist Physiotherapist at Beacon Hospital. For more information or to make an appointment, visit beaconhospital.ie/pelvic-floor-centre.
Top photo: Bridget Jones’ Baby; all other photos via Pexels
Read more: Postpartum incontinence: ‘The indignity of wetting myself every day was a lot to deal with’
Read more: UTIs explained: 23 burning questions about urinary tract infections
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