You know that something is wrong when you feel as if your bladder is no longer in your control, or worse, that it is controlling your life.

You are not alone

You are not alone in this. It is estimated that 1 in every five women will have a bladder control problem at some point during her life. The numbers are much higher with advanced age. A study performed on young athletic paratroopers that had never been pregnant and had never given birth revealed that many of them leaked upon impact with the ground.

Well, most of us carry on an ordinary life style and don’t jump out of airplanes, but this demonstrates that the urinary system is not designed to withstand such forces. Under regular daily circumstances, most women will remain dry and will get on with their lives without paying much attention to their bladder control. Many women, however, will have urine leakage or have other voiding complaints.

Bladder control problems can be categorized into one of the following:

Stress urinary incontinence - You leak when you cough, sneeze or strain

As opposed to what the name may imply stress urinary incontinence has nothing to do with emotional stress. Stress is usually associated with an unpleasant feeling of being anxious, worried, and at unease. Although most women are distressed by their urinary leakage brought on by coughing sneezing or straining, this type of urinary incontinence is not caused by any emotional stress.  Straining causes the leakage. It is this straining effort that increases abdominal pressure when you cough, sneeze or bend over to lift that gallon size milk bottle for example. Factors that will put you at risk for developing stress incontinence are childbirth, pregnancy, aging, menopause, and history of hysterectomy (removal of the uterus), obesity, and functional and cognitive difficulties.

What really happens (for the technical minded)

In Figure 2 (yellow background, below) you will see an anatomical illustration of the pelvis in a woman who does not have stress urinary incontinence. In the left picture you will see that the urethra and the bladder are both in their normal anatomical position above the muscles of the pelvic floor. In the right picture you can see an illustration of the same woman at a time of straining (such as when she laughs, coughs or sneezes) where her abdominal pressure is increased. Since both her bladder and urethra are above the pelvic floor and within the same area of increased pressure, they will both be exposed to the increase in pressures. No leakage of urine will occur at this stage

Now look at Figure 3(green background, below). This is a drawing of the pelvic anatomy of a woman with stress urinary incontinence. Note in the left picture that the bladder neck and the urethra are not well supported by the pelvic floor while the bladder itself is still above the pelvic floor. When the abdominal pressure increases (picture on the right) the bladder will be exposed to this pressure but the urethra, being outside of this elevated pressure zone will be exposed only in part to this pressure or not at all. In this case, the pressure elevation in the bladder will be higher than in the urethra. The result will be urinary leakage.

Figure 2 (with yellow background) is of the pelvic anatomy in a woman who does not have stress urinary incontinence: Left picture: without straining, right picture: with straining. (click on image to get a larger graphic)- Illustration by Florence Adar

Figure 3 (with green background) is of pelvic anatomy in a woman who has stress urinary incontinence. Left picture: without abdominal straining, Right picture: with abdominal straining.- Illustration by Florence Adar

 If the uretheral sphincter—the muscle that serves like a gate to the bladder—is weak, incontinence will occur even if the bladder neck and urethra are well supported. This will result in stress urinary incontinence.

Urge urinary incontinence - You feel a strong urge to urinate, you rush to the bathroom, but can’t make it on time.

This is called urge urinary incontinence. Your bladder and urethra can be well supported but your bladder is suddenly contracting for unknown reasons. This will produce high pressure inside your bladder and eventually lead to leakage. It can be a part of the overactive bladder syndrome (which we’ll get to later on).

Mixed urinary incontinence - You have both of the above problems or mixed urinary incontinence

Some women suffer from combined stress and urge urinary incontinence. In its severe form, mixed incontinence is a challenging condition for the patient and the physician alike and usually requires additional testing and adjustment in treatment.  This type of problem will be addressed in the following chapters.

Overactive bladder - You go to the bathroom frequently, you have to rush there being afraid you will not make it on time, you sometimes don’t.

These are all symptoms of an overactive bladder.  An overactive bladder contracts at the wrong times producing high pressure. - Illustration by Florence Adar

Overactive bladder symptoms consist of one or more of the following:

Frequency - When you go to the bathroom so often that it interferes with your daily activities and disturbs you, that is too often.

Most people can easily sit through a whole movie, they will be able to delay their urination when they are in an important meeting or are busy doing something that is important to them. Most people will feel comfortable going to the bathroom once in two and a half to three and a half hours. If you have to stop for a restroom break while you drive to work even though it is just a 30 minute drive, if you know all the public restrooms in the vicinity of your neighborhood and shopping area, than you have overactive bladder syndrome.

Usually the number of times you urinate depends on how much you drink. The more you drink the more often you will use the restroom. Many women are “natural drinkers” they just like to drink a lot. Other women are advised by their doctor, gym instructor, or dietician to drink a lot or “to flush the system”. Excessive drinking is unnecessary in most cases and especially so if you are already troubled by frequent urination.

Nighttime frequency (or nocturia) - This is when you wake up from sleep at night because you need to empty your bladder. Waking up at night for other reasons such as a bad dream or restlessness for example, and then using the opportunity to get up and urinate is not in this category. There is no clear-cut definition of what is normal and what represents a problem but most women find it bothersome if they wake up to urinate 2 or more times at night. The number of times you get up at night is determined by what you drink before you go to bed. If your pre-sleep routine includes a cup of coffee, tea, and a hot chocolate, you will most probably need to urinate during the nighttime.

Urgency - This is the fear of losing control: you need to go to the bathroom and you need to do it now! You cannot wait or you will otherwise wet yourself. You have experienced it at least once in your life: You were away from home, driving 3 hours and became aware that your bladder is full but you know you can still hold it in. You arrive at your parking spot next to your house; you start to feel that you really need to go badly. You arrive at the door and reach for your keys. You will put the key in the keyhole and try to open the door.

This is where many people will feel a real strong urge or urgency. This is a learned instinct.  We have learned from our past experience that we will be able to urinate soon. It is somewhat like our mouth watering when we smell good food. This is an experience shared by many, but if you experience it nearly every time you use the restroom you have overactive bladder.

Urge urinary incontinence - When you have the urge as described above, but you cannot make it to the bathroom on time and you leak on yourself on the way there.

Pelvic organ prolapse

Your bladder (or other pelvic organs) are  “falling out” of your vagina.

Your pelvic floor supports all of your pelvic floor organs. These organs are also supported by connective tissue around them. A weakness of the pelvic floor or the supporting structures can lead to a “fall” of one or more of these organs. This slackening of support and the resulting “drop” of the structures are defined as pelvic floor prolapse. The prolapse can be very mild so you will never be aware of it and it will never affect your life. It can be, however, advanced to a degree you will be able to see or feel a bulge between your legs. The function of the prolapsed organ can also change and difficulties while urinating, defecating and during sexual intercourse can result.

For the technical minded

For those of you who want to go into pelvic floor prolapse further, or for anyone even slightly interested here are some more definitions that you might like to know:

Different names are given to the different protruding organs:

Cystocele is the  prolapse of the bladder

Rectocele is the prolapse of the rectum

Uterine prolapse is the prolapse of the uterus

Vaginal vault prolapse is the prolapse of the dome of the vagina (vaginal vault) after the uterus has been removed in a previous operation.