In this video, we look at urinary incontinence, which is when your bladder accidentally leaks urine.
 The objectives for this module are:
- to understand how your bladder and lower urinary tract should work;
- to know about different types of problems that can happen;
- to learn about the treatment options for dealing with urinary incontinence; and
- to find out what you can do to help with your symptoms.
Nurse: Urinary incontinence is frustrating and far too common. The following factors can lead to leaky bladder issues:
 having children, your genetics (which means you have a family history of urinary incontinence)
 getting older, smoking
 having extra weight, having issues with constipation and straining,
 doing activities with lots of high impact with the ground, or lifting heavy things
 taking some types of medicine that might bother your bladder, and consuming some foods and drinks
 First we look at how your bladder typically works.
 Your kidneys filter everything you eat or drink.
This makes urine, which drains through the ureters—the 2 yellow tubes you see—to your bladder, which acts as a urine storage tank.
Your bladder can be different sizes depending on how full it is. Urine drains out from your bladder through your urethra.
Your bladder is made of 3 layers of muscle.
The inner muscle, called the detrusor muscle, contracts and relaxes like a balloon that you inflate and deflate.
This bladder muscle is normally relaxed as it fills and contracts when it empties urine.
When you go pee or drain your bladder, you can stop the urine from draining by tightening your pelvic floor muscles which circle around the urethra.
When the detrusor muscle contracts, you then can relax these muscles so urine drains out.
The walls of your urethra have many estrogen receptors in them.
Before menopause, they are plump, moist, and healthy and can stay closed better.
As your estrogen levels go down with aging, your urethra may not be as plump and moist, and it may not stay as tightly closed.
 Your bladder system is quite complicated.
To understand it better, let's look at 2 phases—the filling phase and the emptying phase.
As your bladder begins to fill, you should feel like you need to pee as your bladder contracts.
When you're on the toilet, you consciously relax the muscles around the urethra, or the external sphincter.
The detrusor muscle pushes urine out, which causes the pressure in your bladder to go up, as you can see by the line going up in a wave.
There's always a bit of urine left after you empty your bladder.
When you're done, the cycle begins again.
 The healthy bladder holds about 350 to 650 mL, or 1 to 2 cups, of urine.
You should be able to hold your urine for about 3 to 4 hours and pee about 6 to 8 times in 24 hours.
Ideally, you should not need to wake up in the night to pee, but it's not uncommon to get up once or twice as your body processes the fluids you drank later in the day.
It's helpful to keep track of how often and when you pee, called your voiding pattern, using a voiding diary.
We talk more about this later.
 There are different types of incontinence.
Noticing your symptoms will help you know what kind you have and the best ways to manage it.
 Stress incontinence and overactive bladder are the most common types of incontinence.
You may have a bit of both, called mixed incontinence.
Overflow incontinence, functional incontinence, and nocturia are less common.
We talk about them later in this video.
 Stress incontinence is when activities like coughing, sneezing, jumping, laughing, running, or sex put pressure on your bladder and cause it to leak urine.
With stress incontinence, you don't need to use the bathroom that often and you can control any urge to pee.
 You may leak anywhere from a few drops to a gush or even a lot of urine.
When there's pressure on your bladder, your urethra can't stay tightly closed (like the dotted line shows) and the muscles cannot tighten enough to stop urine from leaking.
It acts like a leaky tap.
This can start when you are younger and may get worse as you age.
It rarely starts when you get older.
 Here are the treatment options for stress incontinence.
We'll get into more detail about each option in a moment.
The first option is to strengthen the pelvic floor muscles around your urethra, which is important for every type of pelvic floor issue, not just stress incontinence.
You can learn a lot more about this by watching the video called Exercising Your Pelvic Floor.
Another option is wearing a pessary for stress incontinence.
Surgery is another option.
And so is having healthy bladder habits to help with stress incontinence so you leak less often.
Now, a pelvic floor physiotherapist will tell you how to find and use your pelvic muscles to prevent stress incontinence.
Physio: Hello, I am a pelvic floor physiotherapist, and I will tell you about how training your pelvic floor muscles can help with leaky bladder problems.
 The pelvic floor is a hammock of muscles and ligaments that extends from the back to the front and from side to side across the bottom of your pelvis.
 They attach to your pubic bone in the front,
 to your tailbone at the back, and
 between your sitting bones on each side.
The three openings through the pelvic floor are the
 urethra, through which you pee, in the front,
 the vagina in the middle, and
 the anus in the back.
Physio: The pelvic floor muscles tighten and close around these three openings to stop any urine, stool, and gas from leaking out.
They keep you dry.
They must also be able to relax so you can empty your bladder and bowels when you need to and have pain-free sex.
They also help support your pelvic organs inside.
 These muscles also help you with your posture as they work together with your deep abdominal muscles, deep low back muscles, and your breathing muscle, the diaphragm.
Physio: The pelvic floor muscles also play a part in how you feel and enjoy sex if they are healthy.
How can you find and feel your pelvic floor muscles?
 Can you stop or slow the flow of urine halfway through emptying your bladder?
Please don't do this as an exercise, but as just a test to see if you can find these muscles.
If you can slow the flow, you are using the muscles more towards the front of the pelvic floor that are around your urethra.
Secondly, can you to squeeze the muscles around your vagina?
Imagine squeezing a tampon or closing the vaginal opening.
These muscles are in middle part of your pelvic floor.
Can you tighten the muscles around your anus, as if you are trying to stop passing gas?
This is part of the muscle group more toward the back of the pelvic floor.
If you are not sure if you are using the right muscles, check with your family doctor, nurse, or pelvic floor physiotherapist.
 Physiotherapy Alberta can help you find a pelvic health physiotherapist to help you find and exercise these muscles.
Let's talk about how to do pelvic floor muscle exercises.
 When you try to do these exercises, it is helpful to think about closing the three openings as your pelvic floor muscles lift “up" inside.
 Try to think of closing an elevator door and then the elevator moving up towards your head.
As you tighten these muscles, do not tighten your legs, bottom, or tummy.
 Do not push down or hold your breath.
As well, it is also just as important to fully relax the muscles after you tighten or squeeze.
Think about the elevator coming back down after lifting up.
There are two different ways to do these exercises:
 One way is to do them slowly.
Close the openings, and pull up and in slowly and hold for up to 10 seconds at a time.
Relax completely after each one.
Repeat 10 times in a row.
 Another way is to do them quickly squeezing and lifting the muscles, holding for only 1 second, and then releasing them.
Repeat up to 10 times.
 Do these at least three times a day, repeating the exercise 10 times each session.
Squeeze and relax.
You need to do these exercises for the rest of your life.
Start in positions that are easier for you to feel your pelvic floor muscles, such as lying down or sitting.
Physio: It can take 6 to 8 weeks of exercising every day to see that your stress incontinence is getting better.
You may notice that you no longer leak, or leak less when you cough or sneeze or exercise because now you can tighten your muscles around your urethra.
You may find that when you feel the urge to go pee, you can hold it back by tightening these muscles.
Just remember that like any exercise program, you must keep exercising so the muscles strong.
As the saying goes, “if you don't use it, you lose it."
To stop urinary incontinence from happening, it's important to get into the habit of squeezing your pelvic floor muscles before you lift, cough, sneeze, or laugh.
Over time, you can train yourself to squeeze without thinking, but for a while, you will need to remember to do it.
 It is important to use good posture with everything you do, as well as when you tighten your pelvic floor muscles.
Physio: If you want more information on how your day-to-day and leisure activities can affect your pelvic floor muscles and incontinence, watch the video Exercising Your Pelvic Floor by on the main menu of this website.
 Nurse: Next let's look at using a pessary to help stop leaking urine.
 A pessary is a device that you put into your vagina, next to the bladder.
It works by supporting your urethra to not open when you cough or sneeze, causing you to leak urine.
 Pessaries for stress incontinence have a knob on one side.
You can use them all the time or part-time, depending on your needs.
You may be able to take care of them on your own, they are simple to take out and put in, and you can clean them with tap water and soap.
 You will need to be properly fitted for a pessary by an expert, or the pessary may not work as well.
You need to pay for the pessary, and sometimes you need to buy more than one to find the one that will work the best for you.
Nurse: You need to try a pessary in everyday life to know how well it will work. They are a good option for stress incontinence that many people don't know about. Combined with strengthening your pelvic floor muscles, you may find you rarely leak at all.
On the main menu, you will find a video about pessaries and how to use them. It gives you more information about using pessaries for stress incontinence.
 Another option for treating stress incontinence is surgery.
Here is a urogynecologist to tell you about surgeries for stress incontinence.
Doctor: Surgeries for stress incontinence work to either bulk up or plump up the urethra or support the urethra by using a type of sling.
Your surgeon will talk to you to help you decide what is the best choice for you.
 Bulking up the urethra is done by a trained surgeon.
A bulking solution is injected around your urethra to plump it up so it stays closed better.
After the procedure, you can get up and go back to your normal activities right away.
This surgery may not last as long as other surgeries, and you may need to come back for more injections in the future.
 Here is another view of the bladder and urethra, and the bulking solution that is injected into either side of the urethra, bulking it up to help keep it closed to stop leaking.
 Surgeries that give support under the urethra are the most common surgeries for stress incontinence.
They use a tape or sling between your urethra and vagina to help stop leaking. These surgeries are called tension free vaginal tape procedures (or TVT) or transobturator tape procedures (or TOT).
They're done through a small incision through your vagina or, less commonly, your tummy.
 Here you see how the sling supports under the urethra, helping to keep it closed at the neck to help stop leaking.
Doctor: Surgeries for stress incontinence usually work better than other treatment options, but they have risks, or complications, you should know about.
The most common complications after stress incontinence surgery are having trouble emptying your bladder or having overactive bladder symptoms (which Nurse will talk about).
The meshes used for the slings are permanent, and your surgeon will talk about possible problems with the mesh.
If you're thinking about surgery, your surgeon may do tests before surgery to know your risk of complications.
Be sure to ask your surgeon all the questions you have and make sure you understand the answers.
 There are a few things to remember about stress incontinence surgeries.
You can't have these surgeries if you are planning to have more children.
You can have stress incontinence surgery at the same time as prolapse surgery.
And it is important to know that these surgeries do NOT work for symptoms of overactive bladder and can even make it worse—they are only for stress incontinence.
 Nurse: Now let's talk about healthy habits for stress incontinence.
 These healthy habits may not completely cure stress incontinence, but they're good habits to help your bladder work better.
One healthy habit is being at a healthy weight.
For some, this could mean weight loss.
There is evidence showing that as little as a 10% weight loss can help with leaky bladder symptoms.
Losing weight could mean making changes to what you eat and also to your exercise.
It can be challenging to exercise if it makes you leak, but it might help your symptoms long term.
Try to empty your bladder about every 3 to 4 hours.
Don't push to pee—let your bladder muscle push the urine out, so take your time on the toilet.
Also make sure you are drinking enough fluids.
We talk more about this in the next part.
 This next common type of incontinence is overactive bladder.
The symptoms include a sudden and strong urges to pee, such as when you get home or even hear water running.
The urge can be so strong that you don't make it to the toilet in time and you leak.
You may also feel you need to pee very often—much more than every 3 to 4 hours.
You may need to get up and pee a lot at night, have trouble getting to the toilet on time, or even wet the bed.
Things like bladder infections or bladder stones can cause overactive bladder, but mostly it's caused by mixed-up messages between your bladder and your brain.
 Just like with stress incontinence, there are many things that can help with overactive bladder.
The first is exercising your pelvic floor muscles, which the physiotherapist talked about earlier in this video.
 When you have the urge to pee, you should be able to hold your urine using your muscles.
 Let's talk about healthy habits again and add a few that are important for overactive bladder.
 Your bladder needs enough fluid to work properly.
So what should you drink, and how much?
Water is the best choice, but you can drink other fluids too.
Try to drink 6 to 8 cups a day.
You may need to drink more or less, depending on your activities or if it's hot.
Drink enough so your urine is a pale yellow colour, not deep yellow or orange, unless you are taking vitamins that change the colour.
Not drinking enough puts you at higher risk of bladder infections.
Strong urine can irritate your bladder wall, making you feel like you need to pee more often even when there isn't much urine in your bladder.
Also try not to drink too much, which can put extra strain on your bladder.
If your urine is clear with no colour, you may be drinking too much.
 Some things you drink or eat may irritate your bladder.
Caffeine can be a problem, especially if you drink caffeinated beverages regularly.
Caffeine makes your bladder fill quickly, and it irritates the bladder wall, which can give you a strong urge to pee.
Try to have less caffeine or none at all.
Acidic juices and fruits—including tomatoes and tomato products—will also bother your bladder if you drink a lot of them.
A glass of orange juice will meet your needs for vitamin C, but it may irritate your bladder.
Cranberry juice, alcohol, very spicy foods, and artificial sweeteners can also bother your bladder, as well as other foods.
 If you feel like you can't empty your bladder completely, you can do what's called a double void.
After your urine flow stops, lean forwards and back, side to side, even stand and sit back down.
Then lean forwards and allow the stream to start again.
It may not be as strong or last as long, but you may be able to empty more fully.
 Smoking bothers your bladder.
The ingredients of cigarettes irritate the bladder wall and cause it contract.
Smoking for many years can cause chronic coughing.
Smoking is also one of the main causes of bladder cancer.
 There are urge control techniques that you can use when the urge to pee is sudden and strong.
 These techniques take time and practice, but they can work very well to stop leaking.
The urge to pee comes usually in a wave, builds to a peak, but does fades away.
First—do not run to the toilet—you cannot outrun your bladder!
Try to sit down, then relax—think of something different and take some deep breaths.
Do some pelvic muscle contractions and hold that urine back.
The urge will go down — like a wave does—and then, if it has been a few hours since you last went pee, walk to the bathroom with control or wait until later to go.
 Bladder retraining can also be useful if you are going to the bathroom a lot.
 Bladder retraining works to put more time between your trips to the bathroom, so your bladder gets used to holding more over time.
You will need to follow a schedule you control.
Set reminders with a watch or a phone.
To start, if you usually pee every hour, set a reminder and pee every hour during the day.
Do this for one week and go to the bathroom only at this regular interval.
 Try and increase this interval each week for a longer time—15 to 30 minutes each week—and again, stick to it.
Continue until you are able to hold your urine easily for a longer time.
This has been shown to be an effective way of retraining your bladder.
At night, just try and sleep through.
You can use a bladder diary to keep track of your voiding schedule, as mentioned earlier.
 There are medicines that can help overactive bladder.
[Doctor] will discuss how these medicines may work for you.
Doctor: Your nervous system tells your bladder what to do with the signals that come from your brain and spinal cord.
But an overactive bladder reacts too quickly to these signals.
Using medicines to help block these signals will help relax your bladder so it can hold more.
You will then pee less often and not always feel like you need to go.
You need to take these medicines every day, not just once in a while.
And they work best if you also follow the other suggestions from this video.
 There are three categories of these medicines: anticholinergics, antispasmodics, and adrenergic receptor activators.
Having more than one choice means you can try something else if one does not work.
Your doctor will talk with you about the medicine that may be best for you as well and tells you about any side effects.
Some common side effects include dry mouth, dry eyes, and sometimes constipation.
There is one more option if the medicines do not work for you.
It is Botox or the botulinum toxin.
Botox relaxes the bladder by paralyzing some of the muscles of the wall.
It needs to be injected right into the bladder wall and is done as a procedure.
 Using a vaginal estrogen may also help your symptoms.
With menopause, your estrogen levels drop and the urethra and bladder become more easily irritated.
You may think of it like dry skin which can be itchy and may even burn a bit. You may feel the need to pee all the time.
By using estrogen in your vagina, your tissues will become healthier and less irritated.
That may be enough to control your symptoms and improve control.
There are also other reasons you may have overactive bladder symptoms.
A common one is bladder infections.
If these are a problem for you, talk to your doctor.
Using vaginal estrogen may help as well.
 Do you have any symptoms of stress incontinence or overactive bladder—or both?
This is called mixed incontinence, and you may need to use treatments for both of them.
Surgery only is done for stress incontinence and medicines are only for overactive bladder.
But some of the other treatment options, like strengthening your pelvic floor muscles, are helpful for both types.
 Now let's look at less common bladder issues.
The first is “overflow Incontinence."
You may only feel the need to empty your bladder once or twice a day.
If you're used to waiting to empty your bladder, for example, in some jobs like nurse, teacher, or cashier, it can be hard to take bathroom breaks.
Your bladder can stretch over time as you keep making it wait to empty.
 But you may end up with an overstretched huge bladder that may no longer works as it should and stops giving you the sensation to empty it.
At times, you may no longer feel any urge to go—and all of a sudden, you are wet.
Your bladder fills up and spills over when it gets full enough.
This can also happen when your urethra becomes blocked, perhaps due to prolapse issues described in the last video.
There are also medicines that make it harder for you to pee.
 You can't fix overflow incontinence with surgery or medicines.
The best way to deal with it is to empty your bladder on a timed schedule—say, every 3 hours—so it won't get so overfull and spill over.
If this does not help then you may need to self-catheterize (use a small tube to empty your bladder).
Not emptying your bladder well can raise your risk of a bladder infection.
 Functional incontinence has less to do with your bladder and more to do with the difficulty in getting to the bathroom.
This is commonly due to some disability that might slow you down.
Perhaps you use a cane, walker, or a wheelchair, and you can't get to the toilet fast enough.
This will make any bladder issue worse.
Even arthritis in your hands may stop you from opening your zipper fast enough.
 It is so important to have strong pelvic floor muscles, so you can hold on better.
And also to make sure you use the bathroom regularly and don't wait too long.
There are also ways to make access easier, even having a commode close by.
 The Alberta Aids to Daily Living Program and Calgary Community Aids to Independent Living are 2 resources to help you get medical supplies and equipment—such as commodes— to make your life easier and help you get to the bathroom easier.
 You might do okay during the day—but not so well at night.
These night time issues are called “nocturia."
It's normal get up to pee once or twice in the night.
It's also normal to make more urine at night as you age.
If you can fall back asleep easily, it's not a problem.
But if you can't fall back asleep, it can affect your quality of life.
 Here are some strategies that may help you.
Limit what you drink after supper.
Your kidneys process the fluids you drink, and if you drink late into the evening, your kidneys will be working while you sleep, causing your bladder to fill and to wake you.
If you stop drinking earlier, there won't be as much fluid to process.
As well, you may keep fluid in your lower limbs because of gravity or circulation issues.
When you lie down to sleep, this fluid can make its way to your kidneys more easily and then to your bladder.
If you go for a walk in the evening and then raise your lower limbs, this fluid may drain back sooner.
Then you can empty your bladder once or twice more in the evening, and less at night when you are trying to sleep.
If you wear compression stockings, keep them on until you go to bed, so they can prevent some of the fluid from collecting in your lower limbs.
If you have swelling in your legs, starting to wear stockings may help.
If this does not help, talk to your family doctor for other options.
And finally, some people get up to pee simply because they wake up.
It becomes a habit: “I am awake—I might as well get up and pee."
It this describes you, try not to get up, but roll over and go back to sleep and break this pattern—if you don't really need to pee.
Or you can try to wait for 15 min every time you wake up.
If after 15 min you still need to pee, then get up and go.
Keep doing this and within a month you should be getting up only once or twice.
If you do wake up, start doing pelvic muscle exercises before you roll over, continue to do them as you sit and regain control, then walk the bathroom with better control.
This works well with the first trip to the toilet in the morning, as well.
 If you need pads to keep your clothes dry from leaking, make sure to use pads designed for urine and not pads designed to hold blood from menstruating.
Incontinence pads hold much more urine, wick it away from the surface, and turn it to a gel.
They prevent odour and reduce irritation to your skin and tissues.
Incontinence pads and products are widely available at drug stores and grocery stores.
There are other products that may help you to keep clean without irritation, like soaps tend to.
 Bladder issues such as incontinence are common problems that can greatly affect your quality of life.
It is important to try to understand the main type of incontinence that is affecting you.
Then you must be clear on what specific types of treatments work for the different types of incontinence.
Make the changes that you can to help with your issues—strengthen your pelvic floor muscles, drink enough of the right fluids, and so on.
Some of the solutions are up to you.
Some your healthcare provider can help you with—like medicines or surgery.
We have given you lots of information.
You can watch this video more than once to help you remember what you have heard.
The final video will wrap it all up and help you think about your next steps.