Urinary leaks: causes, treatments

Often, we hide them with shame and adopt various strategies to “deal with”. However, urinary incontinence is not inevitable and means to get rid of it exist for each case.

Never normal, whatever the frequency and quantity, involuntary leakage of urine would affect 8% of the French population, the vast majority of women. While the embarrassment and discomfort caused by these leaks is constant, the mechanism is not always the same. Urologists thus distinguish l’incontinence d’effort, the most frequent, of urge incontinence (overactive bladder).

In reality, half of women suffer from mixed incontinence according to the Haute Autorité de Santé, associating the two forms, successively or simultaneously. However, no woman or man should suffer from incontinence today, assures Professor Xavier Gamé, urological surgeon at Toulouse University Hospital. So don’t hesitate to talk to your doctor about it.

Urinary leakage triggered by exertion

You just have to cough, laugh out loud, carry your water pack or run to cause more or less abundant leaks. In fact, it is the effort that causes the relaxation of the sphincter bladder (muscular structure capable of opening or closing the urethra), at the origin of these leaks.

What are the causes ? Two mechanisms are involved, explains Professor Gamé. In the first case, the urethra (channel through which the bladder empties) is no longer correctly supported by the perineum, a set of muscles and ligaments that form a kind of “support hammock”. We talk about hypermobility of the urethra. “Imagine a garden hose, water inlet open, compares the surgeon. If the hose is in the sand (defective perineum) and you push down on it, the water will continue to flow. If this same pipe is on tar (tonic perineum), the pressure you are going to exert will be enough to hold the water “.

This lack of support is favored through intensive sports practice which have overworked the perineum (especially with jerks and jumps), obesity, chronic cough (smoking), the constipation (by “pushing”, the perineum is stretched).

Sabine Courtand, physiotherapist specializing in perineal rehabilitation, also sees many women with static disturbances (scoliosis, hyperlordosis) which could contribute to this incontinence. In the second case, stress incontinence is the cause of sphincter insufficiency : the sphincter no longer contracts enough to properly close the urethra and therefore retain urine. This disorder is favored by age, menopause (less hormonal impregnation which leads to loss of tone), a history of pelvic surgery (hysterectomy, tumor removal), poorer vascularization (smoking, atherosclerosis) and obstetric trauma (difficult deliveries).

What treatments? In all cases, the first treatment is perineo-sphincteric rehabilitation, which will cure at least 1 in 2 women, if she is well accompanied by a specialized physiotherapist, a rehabilitation doctor or a midwife.

If the disorders persist, the urologist may suggest to his patient the placement of suburethral strips, which will strengthen the defective pelvic floor. Whatever the technique (retropubic or transobturator strips), this intervention is carried out on an outpatient basis, in about twenty minutes under epidural or general anesthesia (local more rarely). “It gives at least 70 to 80% of good results, assures Professor Gamé, and the strips are still effective twenty years after their application. “

For sphincter insufficiency, an intervention under general anesthesia will allow to place periurethral balloons on either side of the urinary sphincter. “We slide them under the neck of the bladder and then inflate them so that they support and compress the urethra at the same time. It is effective in about 65% of cases.” An alternative : the artificial urinary sphincter. This device is composed of a cuff (an “inflatable ring”) placed around the urethra and connected to a balloon or reservoir (in the belly) which will hold the urine. The assembly is connected to an activation pump implanted under the skin of the labia majora. “In 8 out of 10 cases, this device corrects incontinence, but still few centers offer it in France”, deplores Professor Gamé. As for the injection of fillers (hyaluronic acid) in the wall of the urethra, it is only effective in half of the cases and it is necessary to renew the injection every two years on average. It is therefore rather reserved for older women who cannot be operated.

Urinary leakage caused by an overwhelming urge

This is incontinence called “emergency room”. You feel an irresistible urge to pee when you slip the key in the lock or when you arrive at a restaurant. Impossible to hold back, the first drops escape before reaching the toilet …

What are the causes ? It is favored by age, menopause and obesity which make the bladder more sensitive to distension, irritants such as coffee and tea, but also neurological diseases (multiple sclerosis, Parkinson’s). And, of course, through situations that generate automatic behaviors (sort of Pavlovian reflexes) such as “I’m going home, I’m going to be able to relieve myself”, or even stress, cold, flowing water …

What treatments? It all depends on the cause, but again, we usually start with rehabilitation, which has proven its worth. If these leaks are rather of psychological origin (reflex, stress …), cognitive and behavioral therapies (TCC) give rather good results. We learn to relax, to use different tools to play down the situation, to push back the urge … If this urgency is essentially related to menopause, it will be a hormone replacement therapy local (gel or cream, vaginal ovum).

All other treatments aim to reduce the “overflow” message that the bladder sends to the brain. In the first place, anticholinergics and beta-3 agonists (1 tablet per day), specific drugs to treat overactive bladder. “Both are effective, but we prefer the first (except in case of closed-angle glaucoma), because they are covered by Health Insurance, admits Professor Gamé. Six months after the disappearance of the leaks, the treatment is interrupted to take stock. If any leaks reappear, it is taken back. However, these drugs are accompanied by side effects (feeling of dry mouth, constipation), which sometimes lead patients to discontinue their treatment. We can then offer them stimulation of the tibial nerve by two external electrodes, 20 minutes per day every 24 hours for two months, or more if necessary.

Surgery also relieves some patients. In the hospital, under general anesthesia, the surgeon places a stimulation electrode in the sacrum and a trigger box (a kind of bladder pacemaker) subcutaneously in the back. This electrode delivers an electric current continuously or cyclically. This treatment of neuromodulation, whose mechanism of action is not well known, is reversible and only requires changing the batteries every 5 years, and soon every 15 years. Last resort, you may prefer to inject botulinum toxin into the wall of the bladder in order to partially paralyze it, but the procedure must be repeated every six months and, in 3 to 7% of cases, it causes retention of urine.

Sources :

  • Interview with PR Xavier Gamé, urological surgeon at Toulouse University Hospital and secretary general of the French Association of Urology.
  • HAS, management of incontinence, recommendations.

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