IT is not uncommon for a significant number of women to experience some degree of urinary incontinence (involuntary loss of urine) at some stage in their life and especially during pregnancy and post delivery. However, if the symptoms persist so as to cause a social or hygienic problem with significant disruptions to their daily lives, then it needs medical attention. Bladder control problems can occur both in men and women but are more common in women. These problems can cause significant distress, but women are often reluctant to talk about them probably due to a feeling of shame and embarrassment or the mistaken belief that their problems are a consequence of aging. Although these problems commonly occur in older women, younger women can develop bladder control problems and no one is too young to consult their doctor about them. There are several bladder control problems that can be managed successfully in different ways. These include overactive bladder, stress incontinence and mixed symptoms.

OVERACTIVE BLADDER This is a chronic condition characterized by involuntary contractions of the detrusor muscles of the bladder as the bladder fills up with urine. Characteristic symptoms are increased frequency (of micturation more than 8 times in 24 hours, with nocturia (micturation at night), urgency (a strong and sudden need to void) and urge incontinence (involuntary loss of urine preceded by urgency). These three symptoms may occur alone or in any combination. The prevalence of overactive bladder is estimated as 17 per cent in women over 40 years of age in Europe. The anatomy of the uterus and vagina are such that the bladder and urethra are situated in the front and rectum behind these organs. The pelvic floor muscles and ligaments support these pelvic organs. Stress incontinence occurs when the urethral sphincter functions poorly, due to a variable combination of weakness in the urethral sphincter muscles and an anatomical defect in the urethral support. This leads to insufficient bladder outlet resistance. As a result, involuntary loss of urine occurs whenever there is an increase in the intra abdominal pressure. For example, when patients exert themselves physically, laugh, cough or sneeze. Predisposing factors include congenital weakness of the supports (muscles and ligaments), prolonged and difficult labor, repeated pregnancies with poor spacing and estrogen deficiency.

MIXED SYMPTOMS Some women may experience a combination of the symptoms of both an overactive bladder and stress incontinence. Patients with this condition can therefore suffer from frequency of urination, urgency and urinary leakage.

MANAGING BLADDER CONTROL PROBLEMS Women with bladder control problems may present an overlapping set of symptoms. Therefore, it is important to differentiate correctly between overactive bladder, stress incontinence and mixed incontinence in order to formulate an appropriate management plan. Patients who void urine more than 8 times in 24 hours, suffer from nocturia, urgency, urge incontinence, and leak a fair amount of urine, but do not leak urine during physical activity are likely to have an overactive bladder. Conversely, patients who leak small amounts of urine during physical activity or when they laugh, cough or sneeze are more likely to suffer form stress incontinence. Their condition may or may not be associated with utero vaginal prolapsed. In situations where the symptoms are not clear cut, an uro dynamic examination (which measures the detrusor pressure as the bladder is slowly filled) could be carried out to determine the correct cause.

An overactive bladder is treated most effectively with pharmacotherapy either alone or in combination with bladder training. Anti muscarinic drugs, which block muscarinic receptors in the bladder, reduce involuntary contraction of the detrusor muscles. Bladder training is often used in combination with pharmacotherapy. This is a behavioral approach that aims to increase the patient's time intervals between emptying of bladder. This in turn increases the bladder capacity by teaching patients to resist and suppress the urge to pass urine, thereby giving better bladder control. Milder forms of stress incontinence are usually managed by training the pelvic floor muscles.

The aim is to strengthen the pelvic floor muscles and increase overall muscle tone. Surgery may be advocated in women with moderate to severe symptoms and to those associated with utero vaginal prolapsed. The main aim of the surgical procedure is to support the neck of the bladder and proximal urethra in an intra abdominal position. The principles of surgery is to either pull the bladder and urethra from above (abdominal approach) or to push up the bladder and urethra from below. Occasionally sling procedures are used, especially if there is a recurrence after the initial surgery. Patients with mixed symptoms are managed by treating the symptoms of overactive bladder and stress incontinence separately, taking into consideration the sets of symptoms which predominate.

CONCLUSION Urinary incontinence is a chronic and bothersome medical condition that affects individuals of all ages and inadequate treatment can have serious consequences. Poorly controlled symptoms increase social isolation and may reduce the ability of the individuals to lead a normal and sociable life. By alleviating the symptoms of these conditions with early medical treatment, the quality of life of those affected can be greatly improved, allowing many women to resume their normal lifestyles. The writer a consultant obstetrician & gynaecologist/gynaeoncologist (specialising in women's cancer) and holds a master degree in healthcare management.

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