Urinary incontinence is the involuntary loss of urine. It affects about one in three women at some point in their lives, most often after childbirth and after menopause. Even though it is so common, most women wait years before talking to their doctor, because they feel embarrassed or believe it is “normal for their age.” It is not. In the vast majority of cases, incontinence improves significantly or is cured.
What is urinary incontinence
The bladder stores urine and empties when we decide. For this to work properly, the bladder muscle, the urethral sphincter, the pelvic floor muscles and the nerves that control them must work together. When one of them does not function properly, urine leaks without our control. The amount can be a few drops when laughing or a complete loss before you manage to reach the toilet.
Types of urinary incontinence
Stress incontinence
Urine leaks when pressure in the abdomen rises suddenly: when coughing, sneezing, laughing, running or lifting something heavy. It is caused by weakening of the pelvic floor and the sphincter, and it is the most common type in younger women, especially after vaginal births.
Urge incontinence (overactive bladder)
A sudden, intense urge to urinate that cannot be put off appears, often with frequent urination and waking up at night. The bladder muscle contracts before the bladder is full. It becomes more common with age.
Mixed incontinence
A combination of the two previous types. Treatment starts with the symptom that bothers you most.
Overflow incontinence
The bladder does not empty completely and urine dribbles constantly in small amounts. It is rare in women and is linked to obstruction or neurological problems.
Causes and risk factors
Some causes are temporary, and the incontinence stops once they are treated:
- urinary tract infection or cystitis,
- constipation, which puts pressure on the bladder,
- certain medications, such as diuretics and sedatives,
- excessive intake of caffeine, alcohol, carbonated drinks and artificial sweeteners.
Permanent causes are linked to changes in the support and function of the bladder:
- Pregnancy and childbirth: the weight of the pregnancy and vaginal delivery, especially with a large baby or a forceps delivery, stretch the pelvic muscles and nerves.
- Menopause: the drop in estrogen thins the tissues of the urethra and vagina.
- Obesity: it permanently increases the pressure on the pelvic floor.
- Chronic cough and smoking.
- Uterine or bladder prolapse.
- Previous pelvic surgery.
- Neurological conditions, such as multiple sclerosis and Parkinson's disease, and diabetes mellitus.
How the diagnosis is made
In most cases the evaluation is simple and painless:
- Medical history and bladder diary: for two to three days you record what you drink, when you urinate and when you have leaks.
- Gynecological examination with a cough test, to check the pelvic floor and any prolapse.
- Urinalysis and urine culture, to rule out infection.
- Ultrasound with measurement of the residual urine after voiding.
- Urodynamic testing: it measures the pressures in the bladder. It is needed in complex cases or before surgery.
Treatment of urinary incontinence
Changes in daily life
Losing even 5 to 10% of your weight noticeably reduces episodes. Cut down on coffee, alcohol and carbonated drinks, drink water normally during the day but less in the evening, treat constipation and quit smoking.
Pelvic floor exercises (Kegel)
It is the first-line treatment for stress incontinence. You squeeze the muscles you would use to stop the flow of urine, hold for 5 to 10 seconds and relax for the same amount of time. Ten repetitions, three times a day, for at least three months. If you are not sure you are squeezing the right muscles, a specialized pelvic floor physical therapist helps a lot, with biofeedback where needed.
Bladder training
With urge incontinence, you gradually learn to delay urination and increase the time between trips to the toilet, aiming for three to four hours.
Medication protocol
For overactive bladder, there are medications that relax the bladder muscle. After menopause, local vaginal estrogen improves tissue quality. In resistant cases, botulinum toxin is injected into the bladder.
Minimally invasive and surgical options
When conservative measures are not enough for stress incontinence, the most common procedure is placing a tension-free tape under the urethra (TVT or TOT). It takes about 20 to 30 minutes, is done through small incisions, and the woman goes home the same day or the next. In selected cases, bulking agents are injected around the urethra or laser treatments are used. For the link between incontinence and vaginal laxity, read the article urinary incontinence and vaginal laxity.
Incontinence during pregnancy and after childbirth
Small urine leaks are common in the third trimester and the first weeks after delivery. In most women they resolve within three to six months. Pelvic floor exercises, started during pregnancy and continued after the birth, reduce the chance that the problem persists. If incontinence continues six months after childbirth, an assessment is needed.
When to seek help
- Leaks force you to wear a pad or change your habits.
- You avoid exercise, travel or social outings.
- There is also pain, burning or blood in the urine.
- You feel heaviness or a “ball” in the vagina.
- The incontinence appeared suddenly.
The assessment falls within the field of urogynecology, the specialty that deals with pelvic floor disorders. You can book an appointment at our offices in Athens and Volos.
Urge incontinence often coexists with frequent urination, especially when the bladder is overactive.
Urinary incontinence and pelvic organ prolapse
Incontinence and prolapse often go together, because they share the same root: weak muscles and loose ligaments of the pelvic floor. When the front wall of the vagina gives way, the bladder descends with it (cystocele).
There is a trap here. A large cystocele can “kink” the urethra and mask stress incontinence. The woman has difficulty emptying her bladder, but has no leaks. After the prolapse is repaired, incontinence may suddenly appear. That is why, before prolapse surgery, the doctor checks for incontinence with the prolapse reduced.
Pessaries: a non-surgical option
A pessary is a soft silicone device placed in the vagina that supports the organs. Some shapes also support the urethra, reducing leaks during exertion.
- Suitable for women who do not want, or are unable, to have surgery.
- Useful for women who are still planning a pregnancy.
- It needs regular cleaning and follow-up, usually every few months, to prevent vaginal irritation.
Urine leakage during sexual intercourse
Few women mention it, even to their doctor. Yet urine leakage during intercourse is not rare, especially in women with other forms of incontinence.
- During penetration: it is usually linked to stress incontinence, due to pressure on the bladder and urethra.
- During orgasm: it is more often linked to overactive bladder, where the bladder muscle contracts involuntarily.
In practice, it helps to urinate shortly before intercourse, limit fluids and caffeine in the hour before, and change to positions that put less pressure on the bladder. The real solution, however, is treating the type of incontinence behind it. Do not consider it something you simply have to put up with.
Incontinence during exercise: running, workouts, dancing
Many women stop exercising because they are afraid urine will “escape.” Incontinence during exercise occurs even in young women who have not given birth, especially in sports with jumps and hard landings.
- Preventive contraction: squeeze your pelvic floor one second before jumping, coughing or lifting weights. This technique is easy to learn with a little practice.
- Gradual loading: start with low-impact exercise such as brisk walking, swimming or cycling and build up slowly.
- Vaginal devices: special disposable devices or pessaries support the urethra only during exercise.
- Absorbent products for urine: dedicated incontinence pads absorb and contain urine and odor much better than period pads.
Urinary incontinence after menopause
The drop in estrogen does not only cause hot flashes. It thins the lining of the urethra, the vagina and the bladder trigone. Together these changes are called the genitourinary syndrome of menopause.
Besides leaks, it causes vaginal dryness, pain during intercourse, frequent urination and recurrent urinary tract infections. The symptoms do not ease over time. They usually get worse as the years pass since the last period.
Local vaginal estrogen, as a cream, suppository or ring, is absorbed into the blood only in very small amounts. It reduces recurrent urinary tract infections and improves urgency. For the full range of changes during this stage of life, read the guide to menopause and perimenopause.
Stress incontinence surgery: what to expect
The procedure with a tape under the urethra has been studied in tens of thousands of women. In large studies, about eight in ten women remain dry or significantly improved for many years.
Possible complications
- Difficulty urinating in the first days, which usually resolves.
- New onset of urgency in a small percentage of women.
- Groin pain, more often with the TOT technique.
- Rarely, exposure of the material inside the vagina, which may need correction.
In some countries the use of synthetic tapes has been restricted, so that it is done only after full information and informed choice. Mesh-free alternatives are the Burch colposuspension, which can also be done by laparoscopy, and the autologous fascial sling.
After the procedure
- Avoid heavy lifting and strenuous exercise for about four to six weeks.
- Abstain from sexual intercourse for about six weeks.
- Keep doing pelvic floor exercises to maintain the result.
Myths about urinary incontinence
- “It comes with age, nothing can be done.” Wrong. Most women improve significantly with simple treatments.
- “Kegel exercises are only for young women.” Wrong. Pelvic floor muscles get stronger at any age.
- “A cesarean section fully protects you.” No. It lowers the risk compared with vaginal delivery, but pregnancy itself puts strain on the pelvic floor.
- “If I go to the toilet often ‘just in case,’ I will avoid leaks.” Often the opposite happens: the bladder gets used to holding less urine and urgency gets worse.
Nighttime urination and leakage during sleep
Getting up once a night to urinate is considered common, especially after 60. From two times and up, sleep is disrupted, fatigue builds up and the risk of falling in the dark increases.
Nighttime urination is not always caused by the bladder. Often the body simply produces a lot of urine at night.
- Swelling in the legs: the fluid that collects in the ankles during the day returns to the circulation when you lie down. Raise your legs for one to two hours in the afternoon.
- Diuretics: if you take them, ask your doctor whether they can be moved earlier in the day.
- Sleep apnea, diabetes mellitus, heart failure: all of these increase nighttime urine production and need to be checked if other symptoms are also present.
- Double voiding before bed: urinate, wait a few minutes and try again.
Involuntary loss of urine during sleep in an adult woman is not normal and should always be evaluated.
For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
Is urinary incontinence normal after 50?
It is common, but neither normal nor inevitable. It is linked to the drop in estrogen and weakening of the pelvic floor, and in most women it improves with the right treatment.
Do Kegel exercises really help?
Yes. When done correctly and consistently for at least three months, they improve or cure stress incontinence in the majority of women.
When is surgery needed?
When stress incontinence persists despite exercises and lifestyle changes and affects your quality of life. Placing a tape under the urethra is the most common procedure.
Should I drink less water to avoid leaks?
No. Concentrated urine irritates the bladder and makes urgency worse. Drink normally during the day and limit fluids two to three hours before bed.
Can incontinence be caused by a urinary tract infection?
Yes. A urinary tract infection can cause sudden urgency and leaks. That is why a urine test is the first step of the evaluation.
Can incontinence come back after surgery?
Yes, in a small percentage of women, especially over the years, with weight gain, chronic cough or another childbirth. Continuing pelvic floor exercises and maintaining a healthy weight protect the result. If leaks return, a new evaluation is needed, because it may now be a different type of incontinence.
Is vaginal estrogen safe for long-term use?
Low-dose local estrogen is absorbed into the blood only minimally and is considered safe for long-term use in most women. In women with a history of breast or endometrial cancer, the decision is made together with the oncologist. Any vaginal bleeding during treatment needs to be checked.
Does laser help with urinary incontinence?
Vaginal laser has been studied mainly for mild stress incontinence and for menopausal atrophy. The data are still limited, and international scientific societies do not recommend it as a first-line treatment. Pelvic floor exercises and established procedures have much stronger evidence.
Can I have a baby after incontinence surgery?
You can, but another delivery may reduce the result of the surgery. That is why, if you are planning another pregnancy, it is usually preferable to complete your family first, using exercises, physical therapy or a pessary until then. The mode of your next delivery is discussed individually with your obstetrician.
