This is a conversation I have, in one form or another, almost every week. It usually starts with a different complaint entirely. I’ve changed the details, but not the shape of it.
She came about her knees. We talked about her knees for ten minutes. Then, as I was writing the prescription, she said it, looking at the wall rather than at me.
“Doctor, one more small thing. It’s nothing, really. Sometimes when I cough, or lift the water pot, a little urine comes.”
How long has this been happening?
“Oh, years. After my second child. But it’s become more now. I don’t go for the Sunday prayer meeting any more. It’s a long sitting.”
That last sentence is the one I always notice. Not the leak, but the prayer meeting she no longer attends.
“Isn’t it normal at my age?”
Common, yes. Normal, no. Urinary incontinence, meaning any involuntary leakage of urine, affects a large proportion of women, and many men, as they age. In India we have a curious statistic. In the national Longitudinal Ageing Study (LASI), fewer than 4% of adults over 60 reported that a doctor had diagnosed them with urinary incontinence. Studies that ask about symptoms find it much more often.
I don’t read that as Indians leaking less. I read it as Indians telling their doctors less, and doctors asking less.
“What kind is mine?”
Broadly, there are two main types, and many people have a mix.
Stress incontinence: leakage when pressure on the bladder rises, as with coughing, sneezing, laughing, lifting or getting up. It usually means the pelvic floor muscles and the supports of the urethra have weakened. Childbirth, menopause, chronic cough, constipation and excess weight all contribute.
Urge incontinence: a sudden, strong need to go, and not making it in time. The bladder muscle is contracting when it shouldn’t. This is often part of what we call “overactive bladder”.
“Mine is the first one. The cough one.”
That’s good news, in a way, because it’s the type that responds best to something you can do yourself.
“Is there an operation?”
There are operations, and for some women they’re the right choice. But they’re not the first step. The first step, recommended by every major guideline I know, is pelvic floor muscle training: learning to find, squeeze and strengthen the muscles that hold the bladder and urethra.
The evidence is strong. A Cochrane review of the trials found that women with stress incontinence who did pelvic floor training were about eight times more likely to report being cured than those who had no treatment. Roughly half were cured, compared with about one in twenty without treatment.
“Eight times? From exercises?”
From exercises done properly and done consistently. That is the catch. Many women have been told “do Kegels” in a passing sentence and never shown how. Studies suggest a good number of women, when first asked to squeeze the pelvic floor, actually bear down or tighten the wrong muscles. Supervised training, ideally with a women’s health physiotherapist for at least three months, works much better than a leaflet.
“What else can I do?”
- Don’t stop drinking water. Many women cut fluids to avoid leaking. Concentrated urine irritates the bladder and makes urgency worse, and dehydration brings its own problems. Spread your fluids through the day instead.
- Watch the tea. Caffeine can make urgency worse for some people. Try cutting down for two weeks and see.
- Treat constipation. Straining weakens the pelvic floor.
- Treat the cough. A chronic cough is a constant stress test on the bladder.
- Keep a bladder diary for three days: what you drink, when you pass urine, when you leak. It’s the most useful document you can bring to your doctor.
- Check your medicines. Some blood pressure tablets and other drugs increase urine flow or affect the bladder.
“When should I worry?”
See a doctor promptly if there’s blood in the urine, pain or burning, fever, a feeling of something coming down in the vagina, or sudden new incontinence along with weakness, back pain or confusion.
She came back three months later. She had seen the physiotherapist four times and was doing her exercises “while the rice boils, Doctor, three times a day”. The leak hadn’t vanished, but it was much less, and much less often.
“I went for the prayer meeting last Sunday,” she said. And that, really, was the outcome I’d been hoping to measure.
References
- Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10:CD005654.
- Leng S, et al. Self-reported insomnia symptoms are associated with urinary incontinence among older Indian adults: evidence from LASI. BMC Public Health. 2023;23:552.